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NORTHWEST COLLEGE- DEPT. OF OUTDOOR EDUCATION

 

NWC Climbing Wall Informed Consent/Liability Release

 

 

CLIMBING IS DANGEROUS

I am aware and understand that participating in this activity/class involves a potential risk of minor to severe physical injury, paralysis, or death and understand that this activity/class may be physically and/or mentally demanding and potentially dangerous.  Potential hazards include but are not limited to: travel to and from location, environmental conditions/changes, falls, rope burn, water related injury, hitting body part on fixed objects, resulting in soft tissue, musculoskeletal and/or psychological injury, hypothermia, dehydration or other traumatic event. 

I agree and hereby state that I am solely responsible for my own participation and for my own physical and emotional well-being.  I am aware and understand that all of the program activities are strictly voluntary and it is my own choice to participate in each activity to whatever degree I deem appropriate.  I further state that, in choosing to participate, I am not under the influence of any chemical substance including alcohol. 

I willing and knowingly assume for myself, my heirs, family members, executors administrators and assign all risk of physical injury and emotional upset which may occur during or after participating in any aspect of this activity/class and hereby agree to hold Northwest College, its employees, instructors, facilitators, and agents harmless for liability arising out of my participation in the program.  This release is specifically intended to release Northwest College, its employees, instructors, facilitators, or agents from claims that their negligence caused the harm, injury or damages alleged to have occurred.

I Agree

NWC Climbing Wall Rules:

1.   Only certified climbers can use the climbing wall.
2.   Climbing is only allowed to take place when there is a Climbing Wall Instructor present.
3.   Use the correct rope for each route.
4.   Belayer must always be attentive.
5.   Always be tied in to the climbing rope when climbing.
6.   No climbing above the last hand hold.
7.   Check each other before climbing- Knot tied correctly, Harness tightened correctly, Belay Device set up correctly.
8.   Always use climbing commands.
9.   Participants must wear a shirt at all times and close-toed shoes.
10. Climbing shoes ARE NOT to be worn on the wood floors.
11. Personal Climbing Equipment MUST be checked by Climbing Wall Staff before use.
12. Participants MUST be at least 14 years old to belay.

I Agree

First Climbing Wall Participant's Name

First Name*

Last Name*

Phone*
First Climbing Wall Participant's Date of Birth*
First Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
First Climbing Wall Participant's Signature*
Second Climbing Wall Participant's Name

First Name*

Last Name*
Second Climbing Wall Participant's Date of Birth*
Second Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Third Climbing Wall Participant's Name

First Name*

Last Name*
Third Climbing Wall Participant's Date of Birth*
Third Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Fourth Climbing Wall Participant's Name

First Name*

Last Name*
Fourth Climbing Wall Participant's Date of Birth*
Fourth Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Fifth Climbing Wall Participant's Name

First Name*

Last Name*
Fifth Climbing Wall Participant's Date of Birth*
Fifth Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Sixth Climbing Wall Participant's Name

First Name*

Last Name*
Sixth Climbing Wall Participant's Date of Birth*
Sixth Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Seventh Climbing Wall Participant's Name

First Name*

Last Name*
Seventh Climbing Wall Participant's Date of Birth*
Seventh Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Eighth Climbing Wall Participant's Name

First Name*

Last Name*
Eighth Climbing Wall Participant's Date of Birth*
Eighth Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Ninth Climbing Wall Participant's Name

First Name*

Last Name*
Ninth Climbing Wall Participant's Date of Birth*
Ninth Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Tenth Climbing Wall Participant's Name

First Name*

Last Name*
Tenth Climbing Wall Participant's Date of Birth*
Tenth Climbing Wall Participant's Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
Climbing Wall 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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
NWC ID Number

Click to customize text box label
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 Questionnaire

Enter the Semester and Year you are completing this form. EXAMPLE: "SP18" *
Years of climbing experience?*
Type of climbing experience. (check all that apply) *
No Experience
Indoor climbing
Outdoor climbing
Top Rope Only Climbing
Lead Climbing- Sport
Lead Climbing- Traditional

Level of climbing experience: Yosemite Decimal System (5.0-5.15) Bouldering (V0-V15)

Have you had any previous rock climbing training in the past? If so, what type?
Have you climbed on the NWC Climbing Wall before?*
No
Yes
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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