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Fill up this form in order to climb at Délire Escalade.

WARNING: There are significant elements of risk in any sport or activity associated with a “rock gym” climbing wall, bouldering area and incidental fitness training regimens and equipment (referred to herein as ‘Activity’). Although we have taken responsible steps to provide you with appropriate instructions and/or skilled instructors so you can enjoy an activity for which you may not be skilled, we wish to remind you this

activity is not without risk. Certain risks cannot be eliminated without destroying the unique character of the activity. The same elements that contribute to the unique character of the activity can be causes of loss or damage to your equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death.

 

We do not want to frighten you or reduce your enthusiasm for the activity, but we do think it is important for you to know in advance what to expect and be informed of the inherent risks.

 

ACKNOWLEDGMENT OF RISKS

I acknowledge that the following describes some, but not all the risks of indoor rock climbing:

1. 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;

2. Risk associated with crossing, climbing, or down-climbing;

3. Misuse of equipment or facilities, or failure of equipment;

4. The risk that my health and physical strength, coordination, sense of balance, and ability to follow or give directions while climbing,belaying, or working out may not be sufficient to practice safely the sport of indoor rock climbing;

5. Fatigue, chill and/or dizziness, which may diminish my/our reaction time and increase the risk of accident;

6. Abrasion from or entanglement with ropes and equipment;

7.The presence, actions or falls of other participants be they accredited climbers or not.

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

 

HEALTH AND PHYSICAL CONDITION

I confirm that I am in proper physical condition and I suffer from no personal health issues that prevent me from participating in the activities in Délire escalade. I confirm that I will not climb impaired or while under the influence of any drugs or alcohol.

 

ASSUMPTION OF RISK

I assume the risk(s) of personal injury, accidents and/or illness, including but not limited to: sprains, torn muscles and/or ligaments; fractured or broken bones; eye damage; cuts, wounds, scrapes, abrasions, and/or contusions; dehydration, oxygen shortage (anoxia), exposure and/or altitude sickness; head, neck, and/or spinal injuries; shock, paralysis, and/or death.

 

I assume full responsability for choosing a responsible person to belay me. I understand that through inattention, negligence or for other reasons, my belayer may drop the rope, fail to verify my harness and my knot, or take other actions that could result in my injury or death. I acknowledge the fact that an accreditation at Délire escalade or by any other authority does not mean that the person holding the accreditation is an expert or that they are a responsible person.

 

I assume full responsability of my acts when using the auto belay devices. I understand that the auto belay devices are available when I have no one to belay me. I am responsable to follow the instructions to make sure the device is working properly and that my harness is properly secured on the auto belay carabiner.

 

AGREEMENT TO ABIDE BY THE RULES AND REGULATIONS

I agree to abide by the rules and regulations of Délire escalade and Délire Escalade Lévis inc., which will be explainded, in person by the staff before my first session. A written copy of the rules and regulations will be made available on request.

Délire escalade and Délire Escalade Lévis inc. reserve the right to refuse to accredit any climber who does not pass the Délire escalade accreditation test. Délire Escalade and Délire Escalade Lévis inc. further reserve the right to suspend or remove accreditation from any climber who demonstrates an unsafe attitude toward safety in indoor rock climbing while at Délire escalade, or who does not obey the rules and regulations of Délire escalade.


 

I acknowledge that I requested that this acknowledgement be provided to me in English.

Please read the citation below and sign your initials in the space provided to indicate that you have read and accepted the statement.

 

I accept that Délire escalade and Délire Escalade Lévis inc. may take pictures of me & use them for commercial purposes.

 

I have read and understood the foregoing acknowledgment of risks and assumption of risk and responsibility and that I will abide by the rules and regulations of Délire escalade and Délire Escalade Lévis inc..


First Participant's Name

First Name*

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Phone*
First Participant's Date of Birth*
First Participant's gender
Participant's gender*
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First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's gender
Participant's gender*
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Female
Non-Binary
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Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's gender
Participant's gender*
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Female
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Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's gender
Participant's gender*
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Female
Non-Binary
Prefer not to answer
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's gender
Participant's gender*
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Female
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Prefer not to answer
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's gender
Participant's gender*
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Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's gender
Participant's gender*
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Female
Non-Binary
Prefer not to answer
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's gender
Participant's gender*
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Female
Non-Binary
Prefer not to answer
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's gender
Participant's gender*
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Female
Non-Binary
Prefer not to answer
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's gender
Participant's gender*
Male
Female
Non-Binary
Prefer not to answer
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 legal guardian Email Address

Email
Check to receive information, news, and discounts by e-mail.
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
How did you hear about Délire Escalade?
Choose one *
A friend
Via Facebook
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I saw an add
Other
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 legal guardian Name

First Name*

Last Name*

Phone*
Parent or legal guardian Date of Birth*
Parent or legal guardian gender
Participant's gender*
Male
Female
Non-Binary
Prefer not to answer
Parent or legal guardian 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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