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VITAL Climbing Gym Youth Team Field Trip Permission Slip

LIABILITY RELEASE AND MEDICAL AUTHORIZATION

I consent for my child to participate in the activity named above. I understand that participation in the aforementioned activity, and in all climbing activities and its related and unrelated outdoor ancillary activities, involves a certain degree of risk and can be physically, mentally, and emotionally demanding and could result in severe injury or death. I have carefully considered the risk involved and have given consent for myself or my child to participate in this activity. I release the VITAL Climbing, LLC, the activity coordinators , all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. 

If the Emergency Contact above cannot be contacted and an emergency exists, the undersigned parent or guardian authorizes arepresentative of VITAL Climbing, LLC to consent to X-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care deemed advisable and rendered by any licensed physician or surgeon, whether in the field, in the gym, or in licensed hospital. This authorization is given in advance of any required care and it is to empower a representative or official of VITAL Climbing, LLC to give consent for such treatment as a physician may deem advisable.

Parent/Guardian Signature:

Date: November 18, 2024

First Climber's Name

First Name*

Middle Name

Last Name*

Phone*
First Climber's Date of Birth*
First Climber's Signature*
Second Climber's Name

First Name*

Middle Name

Last Name*
Second Climber's Date of Birth*
Third Climber's Name

First Name*

Middle Name

Last Name*
Third Climber's Date of Birth*
Fourth Climber's Name

First Name*

Middle Name

Last Name*
Fourth Climber's Date of Birth*
Fifth Climber's Name

First Name*

Middle Name

Last Name*
Fifth Climber's Date of Birth*
Sixth Climber's Name

First Name*

Middle Name

Last Name*
Sixth Climber's Date of Birth*
Seventh Climber's Name

First Name*

Middle Name

Last Name*
Seventh Climber's Date of Birth*
Eighth Climber's Name

First Name*

Middle Name

Last Name*
Eighth Climber's Date of Birth*
Ninth Climber's Name

First Name*

Middle Name

Last Name*
Ninth Climber's Date of Birth*
Tenth Climber's Name

First Name*

Middle Name

Last Name*
Tenth Climber's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Field Trip Information

Destination and Purpose of Trip

Start Date of Trip

End Date of Trip

Approximate Departure and Return Times and Locations (if applicable)

Additional Chaperones, Volunteers, and Drivers (if applicable)
Climber Information

Climber's Name

Birth Date

Please explain any physical limitations, medical concerns, or allergies we should be aware of
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 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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