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Acknowledgement and assumption of risk

1) Acknowledgement of Risks and Assumption of Risks

I acknowledge that the inherent risks of using the climbing wall include, but are not limited to:

  • Slips, trips, falls or painful crashes while using the facilities or equipment, climbing walls, bouldering areas, landing pits, floors below climbing areas, work-out areas, bathroom facilities, or stairs;
  • Injuries resulting from falling, including but not limited to, falling into other persons, falling and coming into contact with any walls, structures or ropes, or falling to the floor.
  • The presence, actions or falls of other participants.
  • Fatigue, chill and/or dizziness, which may diminish my reaction time and increase the risk of accident;
  • Abrasion from or entanglement with ropes and equipment;
  • Injuries resulting from my failure to properly use the facilities, climbing walls or equipment including harness and ropes.


I understand the description of these risks and that other unknown or unanticipated risks may result in injury, illness or death. I acknowledge that I am aware of the inherent risks of indoor climbing at Vertige Escalade inc. 

 

2) Confirmation of information and assumption of risks:

I hereby certify that the information consigned to this form is, to the best of my knowledge, exact and accurate. I further certify that no information pertinent or not to my health profile was deliberately omitted. I am aware that the information contained in this form is confidential and will be used to better plan and supervise the safety of the activity in which I will participate and will allow Vertige Escalade inc. to draw up a profile of its clientele. I acknowledge that I was informed about the risks inherent to the activity and I am able to participate in the activity or the stay willingly and I accept any and all risks that such an activity or sty can comprise. I also pledge to play an active role in risk management by adopting a preventive behaviour with regards to my own safety, and the safety of the other persons that surround me. The direction of Vertige Escalade inc. reserves the right to exclude any person he/she deems to be a risk to himself/herself or to the rest of the group. I understand that I may leave the present activity if I drink alcohol or consumed drugs.

 

3) Release and waiver:

In consideration of the use of the VERTIGE ESCALADE INC. :

I agree to waive, for myself and my legal descendants, any claims to which I may become entitled for physical injuries, damages or materials lost. I release of all responsibilities VERTIGE ESCALADE INC., its owners and employees, or any other person assisting in the activities in case of accident or damage caused by myself or at myself.

 

 

Date: August 8, 2020

Please select who will be participating...
AdultMinor
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First Climber's Name

First Name*

Last Name*

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

4) Health Information :

Allergies?*
No
Yes

If yes, specify :
Do you have any physical, psychological or behavioural problems that could limit your participation in your chosen activity? (Ex. : Respiratory or cardiac problems, diabetes, hearing problems, handicap, etc.)*
No
Yes

If yes, specify.

If you have answered YES to any of the questions in section 2, you have to agree and accept the additional risk that your health condition may be aggravated by participating in the activity.

5) Photo consent and email list

I wish to join Vertige Escalade email list and learn about rebates, promotions or events.*
Yes
No
I consent to Vertige Escalade inc, their employees or any other designed person to use photographs or audio-video materials of which I can be model for all general purposes including, without limitation, publishing on printed or electronic document (banners, websites, journalistic articles or commercial purposes), whenever Vertige Escalade chooses to use them. I waive all rights I might have in the photographs. I also acknowledge that I will not receive any future compensation regardless of how my photographs, name and likeness are used.*
Yes
No
First Climber's Signature*
Climber'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*
Check to join Vertige Escalade email list and learn about rebates, promotions or events.
Email me a copy of this document.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

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

4) Health Information :

Allergies?*
No
Yes

If yes, specify :
Do you have any physical, psychological or behavioural problems that could limit your participation in your chosen activity? (Ex. : Respiratory or cardiac problems, diabetes, hearing problems, handicap, etc.)*
No
Yes

If yes, specify.

If you have answered YES to any of the questions in section 2, you have to agree and accept the additional risk that your health condition may be aggravated by participating in the activity.

5) Photo consent and email list

I wish to join Vertige Escalade email list and learn about rebates, promotions or events.*
Yes
No
I consent to Vertige Escalade inc, their employees or any other designed person to use photographs or audio-video materials of which I can be model for all general purposes including, without limitation, publishing on printed or electronic document (banners, websites, journalistic articles or commercial purposes), whenever Vertige Escalade chooses to use them. I waive all rights I might have in the photographs. I also acknowledge that I will not receive any future compensation regardless of how my photographs, name and likeness are used.*
Yes
No
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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