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BRECKENRIDGE RECREATION CENTER

880 Airport Road
Breckenridge, CO 80424

Each part of this form must becompleted to gain admittance to the ROCK CLIMBING WALL

TODAY'S DATE: June 21, 2018

RECREATION CENTER - CLIMBING WALL

PART 1. RELEASE/INDEMNIFICATION OF ALL CLAIMS AND COVENANT NOT TO SUE

1. NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. By signing this agreement, you give up your right to bring a court action to recover compensation or obtain any other remedy for any injury to yourself or your property or for your death however caused arising out of your use of the facilities of the Breckenridge Recreation Center, now or any time in the future.

2. I HEREBY ACKNOWLEDGE AND AGREE that the sport of rock climbing and the use of the facilities of the Town of Breckenridge Recreation Center Climbing Wall (hereinafter referred to as the Wall), its climbing wall and other training facilities, has inherent risks. I have full knowledge of the nature and extent of all the risks associated with rock climbing and the use of the Wall, including but not limited to: 

1. All manner of injury resulting from falling off the climbing wall and hitting rock faces and projections, whether permanently or temporarily in place, or the floor;
2. Rope abrasion, entanglement and other injuries resulting from activities on or near the climbing wall such as, but not limited to, climbing, belaying, rappelling, lowering on rope, rescue systems, and any other rope techniques;
3. Injuries resulting from falling climbers or dropped items, such as, but not limited to, ropes or climbing hardware;
4. Cuts, abrasions, contusions, dislocations, torn muscles and/ or ligaments, and fractured or broken bones resulting from contact with
5. the climbing wall or climbing area floor;
6. Failure of ropes, slings, harnesses, climbing hardware, anchor points, or any part of the climbing wall structure. I further acknowledge that the above list is not inclusive of all possible risks associated with the use of the Wall and that the above list in no way limits the extent or reach of this release and covenant not to use.

3. RELEASE/INDEMNIFICATION AND COVENANT NOT TO SUE. In consideration of my use of the Wall, I, the undersigned user, agree to release and on behalf of myself, my heirs, representatives, executors, administrators and assigns, HEREBY DO RELEASE the Town of Breckenridge, its officers, agents, sponsors and employees from any cause of action, claims or demands of any nature whatsoever, including but not limited to, a claims of NEGLIGENCE, which I, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against the Wall on account of personal injury, property damage, death or accident of any kind, arising out of , or in any way related to my use of the Wall whether that use is supervised or unsupervised, however the injury or damage is caused, including, but not limited to, the NEGLIGENCE of the Town of Breckenridge, its officers, agents, and employees.
In consideration of my use of the Wall, I, the undersigned user, agree to INDEMNIFY AND HOLD HARMLESS the Town of Breckenridge, its officers, agents and employees from any and all causes of action, claims, demands, losses, or costs of any nature whatever arising out of or in any way relating to my use of the Wall.
I hereby certify that I have full knowledge of the nature and extent of the risks inherent in the use of the Wall and that I am voluntarily assuming the risks. I understand that I will be solely responsible for any loss or damage, including death, I sustain while using the Recreation Center and that by this agreement, I am relieving the Town of Breckenridge of any and all liability for such loss, damage or death.
I further certify that I am in good health and that I have no physical limitations which would preclude my safe use of the facilities.
I further certify that I am of lawful age (18 years or older) and otherwise legally competent to sign this agreement. I further understand that the terms of this agreement are legally binding and I certify that I am signing this agreement, after having carefully read it, of my own free will.
If under the age of 18, this release must be signed by the parent/ guardian of the minor gaining access to the climbing wall.

I Agree

PART 2. CONTRACT TO FOLLOW SAFETY POLICIES OF CLIMBING WALL

The Town of Breckenridge reserves the right to deny access to its facilities to any individual permanently or for a specified period of time for breach of contract in the following Safety Policies, or for any conduct that is viewed as unsafe or inappropriate.

I, the undersigned user of the Breckenridge Recreation Center Climbing Wall, accept full responsibility for my own safety and the safety of other climbers while on the premises of Breckenridge Recreation Center. I agree to abide by, and to help enforce, the following Safety Policies:

1. All users must have a signed Waiver of Liability Form on file and have had their skills assessed by climbing wall staff.
2. All users must pass a skills assessment yearly or be accompanied by an instructor to use the wall.
3. An adult must accompany users under the age of 14.
4. Use of a helmet is recommended. Helmets are available through the climbing wall staff.
5. Bouldering is allowed only to the designated heights.
6. All personal equipment must be used in accordance with manufacturer instructions. All users must acknowledge, assume and accept ALL responsibility for the proper selection, use, care, maintenance, inspection and storage of any personal climbing equipment.
7. Use proper climbing commands before each climb.
8. No horseplay allowed in the climbing wall areas.
9. No food or drink allowed in the climbing wall areas.
10. Please inform staff of any unsafe situation or violation of safety policy. All accidents or equipment damage must be reported.
11. Climbing has inherent risks and cannot be made completely safe. Climb at your own risk. In consideration of the use of the Wall,

I acknowledge that I have read and agree to abide by the Safety Policies.

I Agree

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*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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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