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This statement requires each participant to verify that they are medically fit to climb.

Medically Fit Statement

I hereby confirm that I have read and understood the risks involved in training, and I confirm that I am medically and physically fit to participate in all training.

I understand and confirm that no factors will prevent or affect my participation in training. 

I agree to adhere to all instructions given by my instructor(s) throughout the duration of my training. If there is any doubt or concern about my medical fitness, I understand the training provider will stop training and seek a physician’s advice.

Medical Fitness: 

As a participant, I understand that activities at height are physically demanding, and physical fitness is a necessity. Upon my attendance, I am stating that I, as the participant, am in good physical health and capable of safely meeting the needs for medical fitness.

Weight Limits:

 I acknowledge that the weight requirement for myself, and all other participants, is a minimum of 130 lbs and a maximum of 310 lbs while wearing all necessary PPE (personal protective equipment*).

*PPE for Working At Height training will include a harness, lanyards, helmet, etc.

Conditions and Risks: 

I understand that there are conditions that will potentially make my participation in training inadvisable. I acknowledge that some medical conditions are definite risks to safe and effective work at height training. 

These conditions include but are not limited to the following:

·   Alcohol or drug dependence

·   Allergies (e.g., bee/wasp stings or spider bites)

·   Angina or other heart complaints

·   Arthritis, osteoarthritis, or other muscular/skeletal disorders affecting mobility

·   Asthma or other respiratory disorders

·   Blood pressure disorder

·   Claustrophobia/acrophobia (fear of enclosed spaces/heights)

·   Diabetes

·   Epilepsy, blackouts, or other seizures

·   Recent surgery

·   Vertigo or inner ear problems (difficulty with balance)

·   Any other medical condition or medication dependency that could affect climbing or the physical impact of climbing

I understand that I am participating in training at my own risk and am absolving Optimum Rope Access Solutions, Inc. (Optimum Academy, Optimum) and all Optimum employees of liability.

I understand that my employer may require a pre-participation physical release from a doctor or licensed healthcare provider if I have any medical conditions that pose a risk to myself during training or to my employment.


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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