PO Box 511 | Oaks, PA 19456

WARNING: There are significant elements of risk in any adventure, sport, activity or training associated with a rock gym or climbing wall or rock climbing or bouldering (referred to herein as activity) and the use of any equipment.

ACKNOWLEDGMENT OF RISKS: I recognize that there is an inherent risk of danger in this type of activity. These risks may result in serious injury or death and include but are not limited to 1) Falls; 2) Risk associated with crossing, climbing or down climbing; 3) Equipment failure; and 4) My physical coordination, sense of balance, decision making, and ability to follow or give directions either as a climber or belayer. I also acknowledge that certain foreseeable and unforeseeable events can contribute to the unpredictability of the activity; that personal property may be damaged or lost and that wearing appropriate clothing and footwear are basic safety precautions.

EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: In recognition of the inherent risks of which I and any minor children for which I am responsible, will engage in, I confirm that I am (we are) physically and mentally capable of participating in the activity and/or using equipment. I/we participate willingly and voluntarily and I assume full responsibility for personal injury, accidents or illness (including death), and any expenses as a result of my negligence or the negligence of any minor children for which I am responsible. I also assume responsibility for damage to or loss of personal property as the result of any accident that may occur. I also assume risk for accident or injury caused by the negligence of my belayer whether such negligence is comparative or contributory. I assume the risk(s) of personal injury, accidents and/or illness, including but not limited to sprains, torn muscles and/or ligaments, fractured or broken bones, eye damage, cuts, wounds, scrapes, abrasions, and/or spinal injuries, animal bite or attack, insect bite or allergic reaction, shock, paralysis, drowning, and/or death, and acknowledge that during the activity I/we may experience fatigue, chill and/or dizziness which may diminish my/our reaction time and increase the risk of an accident.

COVENANT OF GOOD FAITH: I recognize that you, as a provider of services, will operate under a covenant of good faith and fair dealing, but that you may find it necessary to terminate an activity due to forces of nature, medical necessities, or problems in the group, and/or refuse or terminate the participation of any person you judge to be incapable of meeting the rigors or requirements of participating in the activity. I accept your right to take such actions for the safety of myself and/or other participants. I acknowledge that no guarantees have been made with the respect to climbing objectives.

AUTHORIZATION: I hereby authorize any medical treatment deemed necessary in the event of any injury or illness I incur while participating in the activity. I either have appropriate insurance or, in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my/our behalf.

RELEASE: In consideration of services or property provided, I, for myself and any minor children for which I am parent, legal guardian or otherwise responsible, and any of their heirs, personal representatives or assigns, do hereby release: Philly Rock Corp, PRG Climbing Center, Inc., PRG Holdings, Inc., PRG Wyncote, Inc., PRG Fishtown, Inc., Philadelphia Rock Gym, its directors, officers, shareholders, agents, employees, volunteers, independent contractors, vendors, business partners, or any other individuals or entities associated with or connected to the Philadelphia Rock Gym in any way, and each and every land owner, municipal and/or governmental agency upon whose property an activity is conducted, from any and all liability and waive any claim for damage arising from any cause whatsoever, including any damages that may arise in any location or event operating under the Philadelphia Rock Gym name (except that which is the result of gross negligence).

PHOTO RELEASE: I acknowledge that Philadelphia Rock Gym and/or affiliated persons or agents working on behalf of Philadelphia Rock Gym may periodically be taking photographs and/or recording video of me both inside and outside of its facilities without prior notice. I hereby irrevocably release, consent and authorize the Philadelphia Rock Gym and its affiliates and agents to copyright, use and publish my photograph/likeness/voice as it pertains to my participation with the Philadelphia Rock Gym, with or without my name and for any lawful purpose including, for example, promotional efforts, publicity, illustration, advertising and Web content and without expectation of or right to any remuneration in connection with such use.


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First Participant's Name

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Middle Name

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First Participant's Date of Birth*
First Participant's Signature*
Participant's Address
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Emergency Contact

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Parent(s) or 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

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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