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Climbing Gym Release of Liability and Assumption of Risk

The participant (or supervising parent/guardian) should read the following carefully and initial where indicated. The document should then be signed by the participant (or supervising parent/guardian) in the signature box.

Boulder Shack Induction Video

You must have watched the Boulder Shack Induction Video and be confident that you understand the risks involved in participating in indoor bouldering

Risks & Rules

  • Indoor bouldering carries a danger of personal injury or death. I am aware of and accept these risks and I understand that I am responsible for my own actions and involvement.
  • Boulder Shack is an artificial climbing environment but the risks are no less severe than when climbing outdoors. There is an additional risk that holds can spin or break.
  • The soft matting under the walls does not guarantee your safety. Any fall may result in an injury to the participant or others. We strongly recommend you descend by climbing down carefully.
  • Climbing beyond your capabilities is likely to result in a fall so you must make your own assessment of the risk whenever you climb.
  • Report to reception on each visit before you climb
  • Do not sit, stand or boulder under other people
  • Do not grab or climb over the top of the wall except on the top out boulder where the top of the wall is painted green
  • Do not grab, lean on or in any way intentionally touch the roofing structure
  • Keep bags and personal items in the lockers or shelves, NOT on the mats, floors or walkways
  • Water bottles are not allowed on the mats at any time
  • Avoid uncontrolled falls. Do not jump from the walls
  • Do not wear jewellery, particularly rings, when bouldering, these can catch and cause injury
  • No running anywhere in the centre
  • Report any safety concerns to a member of staff without delay

Initial here to show that you have watched the safety induction video and read, understood and accept the above Risks & Rules of bouldering at Boulder Shack.


Conditions of Use

Duty of Care - The rules of use (above) are not intended to limit your enjoyment of the facilities. They are part of the duty of care that we, as operators, owe to you, the customer, by law. As such they are not negotiable and if you are not prepared to abide by them then the staff must politely ask you to leave. You also have a duty of care to act responsibly towards the other users of the centre.

Free-weight training equipment - The use of the free weights and training aids in the training area (the black rubber-crumbed area around the scaffold bars by the wooden hold training walls) come with additional risks of injuries to yourself and others. This equipment is for those 18 years old or more, unless under the supervision or guidance of a professional coach or physical trainer. Before using any of the weights or training aids in the training area you must ensure you have received professional training or advice on how to use them. This may be from a physical trainer at another gym or by a member of the Boulder Shack Physical Training team. Please ask any Boulder Shack team member for information on how to book this. Boulder Shack is not responsible or liable for any injuries, losses or damages that arise from the use of equipment in this area. Before using any equipment, each time, you are responsible for reading, and following the instructions of the current signage in the vicinity of the equipment you using.

Medical Conditions - If the participant has any sort of medical condition or pre-existing injury this may make it more likely that the participant is injured while bouldering or using the training facilities. Please consult your doctor for advice about the extra risk involved.

Unsupervised Climbing - Unless you are booked on to an instructed group your climbing session will not be supervised by Boulder Shack staff. You should be familiar with the Risks & Rules of Use. These are described in the online safety video and you should ask a member of staff if they are not clear to you. Staff will provide whatever help and advice they can, but instruction in the use of equipment or climbing techniques will only be provided where it has been booked and paid for in advance. If you are not confident in the use of any climbing equipment or technique then do not attempt to use it without the supervision of someone who is competent to do so.

Supervised Climbing - An adult aged 18 or over who has registered to climb may supervise in accordance with the Safe Supervision guidelines and must take full responsibility for the safety of the climbers' they are supervising. Each supervisor (whether climbing themselves or not) may supervise two 6-17 year olds. 4-6 year olds must always have 1 to 1 supervision, with no exceptions. Groups of three or more supervised climbers of any age must only be supervised by an instructor holding the relevant qualification and insurance. 

Your Data- By participating at Boulder Shack Climbing Gym you accept that we will be keeping your data indefinitely, however at anytime you can ask for your data to be deleted. In the event of a First Aid form needing to be filled out we will be keep this information for 3 years (form your 18th birthday). We take protecting your data seriously, all of the data that we gather is kept in accordance with the Data Protection Act.  

Initial here to show you have read and understood the Conditions of Use of Boulder Shack 


Dated: May 8, 2021

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
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*
We would love to keep you updated with 1 email a month on upcoming news and events. Check to receive this news.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or 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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Gender & Ethnicity

Equality, Diversity & Inclusion

We want to ensure that we are providing our services to everyone. We recognise that we still have work to do in this area and ask for the below information to help us track our progress. This information is totally optional, but really helpful for our development if you're happy to provide it.

How shall we address you?*
Please choose
He/him
She/her
They/them
I prefer not to say
Let me type below...

Please address me like this
Please indicate your ethnicity (peoples' ethnicity describes their feeling of belonging and attachment to a distinct group of a larger population that shares their ancestry, colour, language or religion) Select all that apply:
African
Caribbean
Caucasian
East Asian
Latino/Hispanic
Middle Eastern
South Asian
Mixed
Other...

If other, please write here
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. You can withdraw your consent at any time. 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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