Loading...

The Synergy Project LLC

PO Box 2143

Chattanooga, TN 37409

PARTICIPANT ASSUMES ALL RISK; INDEMNIFIES THE SYNERGY PROJECT LLC; MAKES A COVENANT NOT TO SUE.

In consideration of the services of The Synergy Project LLC (sometimes doing business as Synergy Climbing or Synergy Climbing Team), their agents, employees, and anyone acting on their behalf, I hereby agree to release, indemnify, and discharge The Synergy Project LLC on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I have voluntarily chosen to engage in climbing activities and also, if participating in a trip or camp organized by The Synergy Project LLC, to be transported within a vehicle leased or owned by The Synergy Project LLC. I understand that engaging in these activities entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks cannot be eliminated.

These risks include, but are by no means limited to: slips and falls; rope burns; pinches, scrapes, jolts, and bumps, cuts and abrasions; infections resulting from cuts or abrasions; impacts from objects or ropes dislodged, thrown, or caused to fall from above; omissions or negligence of The Synergy Project LLC or its employees; the negligence of other participants or persons who may be present, and the effects of physical exertion. When climbing outdoors, additional risks include: wind, rain, lightning; risk of heat- and cold-related illnesses, sunburn, dehydration; and exposure to potentially dangerous animals, insect bites or hazardous plants.

2. I acknowledge that The Synergy Project LLC employees and owners are not infallible. They might act negligently when acting as instructor or driver (if relevant). They might misjudge environmental conditions, my fitness, or my abilities. They might give incomplete warnings or instructions, and any equipment being used might malfunction.

3. I expressly agree and promise to accept and assume all of the risks associated with climbing, and when joining a climbing camp or trip, being transported in a vehicle, including the risks above mentioned and any others unknown to me. My participation in these activities is purely voluntary.

4. I agree that in the event of an emergency, if I should be unavailable, unconscious or otherwise unable to make medical decisions for myself or any minors in my charge, I hereby grant The Synergy Project LLC and its employees or agents permission to administer necessary first aid, and/or to solicit emergency medical services as deemed necessary for my well-being, or the well-being of any minor. This includes permission for emergency transport to a medical facility. I fully release The Synergy Project LLC, its employees and agents, from any liability in connection with those decisions.

5. I certify that I have adequate insurance to cover any injury or damage I may suffer or cause while participating, or else I agree to bear the costs of such injury or damage myself.

6. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless The Synergy Project LLC or anyone acting on their behalf from any and all claims, demands, or causes of action, which are in any way connected with my participation in climbing, my transportation within a vehicle, or my use of The Synergy Project LLC equipment or the equipment of The Synergy Project LLC's employees, including any such claims which allege negligent acts or omissions of The Synergy Project LLC or their employees whether arising through participation in climbing activities or transportation within a vehicle.

7. I agree to indemnify and hold harmless The Synergy Project LLC, or anyone acting on their behalf, for any attorney’s fees and costs incurred to enforce this agreement.

8. In the event that I file a lawsuit against The Synergy Project LLC, I agree to do so solely in the state of Tennessee, and I further agree that the substantive law of that state shall apply in that action. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against The Synergy Project LLC on the basis of any claim from which I have released them herein.

I have read and understood this agreement; I am legally competent to sign it and be bound by its terms.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information And Release
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list all of them: 

Does this participant suffer from hay fever or have any allergies, such as to food, medications, insect stings, poison ivy, or anything else?*
No
Yes

If "Yes" please explain:

Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver