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Pikes Peak Alpine School

TODAY'S DATE: October 24, 2021

MOUNTAINEERING AND ROCK/ICE CLIMBING AND BACKCOUNTRY SKIING RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISK AND INDEMNITY AGREEMENT.

Please read and be certain you understand the implications of signing.

Express Assumption of Risk Associated with Mountaineering, Climbing, Skiing and Related Activities.

I do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Mountaineering, Rock/Ice Climbing and Backcountry Skiing Activities, transportation of equipment related to the activities, and traveling to and from activity sites of which I am about to engage in.

I Agree

Inherent hazards and risks include but are not limited to:

  1. Risk of injury from the activity and equipment utilized in Mountaineering, Rock/Ice Climbing and Backcountry Skiing is significant including the potential for permanent disability and death.
  2. Possible equipment failure and/or malfunction of my own or others equipment.
  3. My own negligence and/or the negligence of others, including employees, agents, independent contractors or representatives of Pikes Peak Alpine School, LLC., including but not limited to operator error.
  4. Injury to hands, fingers, feet and toes, including but not limited to inflammation and/or strains of muscles, ligaments, and/or tendons, nerve damage or compression, and broken bones.
  5. Injuries from falling may occur from exposure to high altitude, which may affect judgment and coordination, or from not paying close attention to your climbing or others climbing with or near you.
  6. Broken bones, severe injuries to the head, neck, and back which may result in severe physical impairment or even death.
  7. Discharge of weapons in or near the area of activity.
  8. Cold weather and heat related injuries and illness including but not limited to frostnip, frost bite, heat exhaustion, heat stroke, sunburn, hypothermia and dehydration.
  9. Exposure to outdoor elements, including but not limited to avalanche, rock fall, inclement weather, lightning, high winds, temperature or weather conditions.
  10. Attack by or encounter with insects, reptiles, and/or animals.
  11. Accidents or illness occurring in remote places where there are no available medical facilities.
  12. Fatigue, chill, and/or dizziness, which may diminish my/our reaction time and increase the risk of accident.
  13. My sense of balance, physical coordination, and ability to follow instructions.
  14. Contraction of or exposure to infectious disease(s).

*I understand the description of these risks is not complete and that unknown or unanticipated risks may result in injury, illness or death.

 

Release of Liability, Waiver of Claims and Indemnity Agreement

In consideration for being permitted to participate in any way in Mountaineering or Rock Climbing related activities, I hereby agree, acknowledge and appreciate that:

  1. I HEREBY RELEASE AND HOLD HARMLESS WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE, the following named person or entities, herein referred to as releasees: Pikes Peak Alpine School, LLC
  2. To release the releasees, their officers, directors, employees, representatives, agents, volunteers, and vessels from liability and responsibility whatsoever and for any claims or causes of action that I, my estate, heirs, survivors, executors, or assigns may have for personal injury, property damage, or wrongful death arising from the above activities whether caused by active or passive negligence of the releasees or otherwise. By executing this document, I agree to hold the releasees harmless and indemnify them in conjunction with any injury, disability, death, or loss or damage to person or property that may occur as a result of engaging in the above activities.
  3. By entering into this Agreement, I am not relying on any oral or written representation or statements made by the releasees, other that what is set forth in this Agreement.
  4. Photographic Assignment:I understand that PPAS reserves the right to take photographic or film (of whatsoever nature) records of any or all of its activities or trips and on behalf of myself and any of the children for which I am responsible I/we hereby agree that PPASmay use such records for promotional and/or commercial purposes without any remuneration to me. I/we hereby assign all right, title and interest I/we may have in or to any and all media in which my name or likeness might be used by PPAS.

This release shall be binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the remaining terms shall be enforceable.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, AND I FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP LEGAL RIGHTS BY SIGNING IT, AND I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I Agree

Please select who will be participating...
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Trip or Course Name *

Date trip begins: *

Height: *

Weight: *

Shoe Size (what is your street shoe size) *

Waist size (in inches) if using our climbing harness. Otherwise type NA.
First Participant's Signature*
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*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additonal Information

List the activities you engage in daily or weekly that indicate your current fitness level. *

Participant's occupation.
Have you had or do you now have (check all that are yes):
Nut/Food Allergy
Severe Bee Sting
Asthma
Diabetes
Angina
Epilepsy
Seizures
Chest Pains
High Blood Pressure
Heart Murmur
Heart Attack
Concussion
Drug Reaction
Shortness of Breath
Muscular-Skeletal Injuries
Fainting
Frequent Headaches
Easy Bruising/Bleeding
Cold Injuries (frostbite)

List date(s) of last occurrence, and explain: (if none, type "none") *

List any allergies: (if none, type "none") *

List current medications taken: (if none, type "none") *

Note any other physical limitations or medical conditions that might restrict your full participation in this program. *

By signing this form, you signify that the above is complete and accurate. 

This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this participant, do consent and agree not only to his/her release of all Releasees, but also to release and indemnify the Releasees from any and all liabilities incident to his/her involvement in these programs for myself, my heirs, assigns, and next of kin.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Trip or Course Name *

Date trip begins: *

Height: *

Weight: *

Shoe Size (what is your street shoe size) *

Waist size (in inches) if using our climbing harness. Otherwise type NA.
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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