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Disclosure of risk form
Birkenhead Pool and Leisure Centre

Activity: Rock climbing

Rock climbing can be a dangerous activity. We are here to ensure that you enjoy your climbing and stay safe. To do this, we need your help.

I declare that:

  • I understand that the activity I am participating in can be dangerous and cause injury or death.
  • I understand that once I have completed the safety briefing by the staff at Birkenhead Pool and Leisure Centre, I am responsible for my own safety when climbing.
  • I understand that my conduct and behaviour must not endanger myself or others participating in the activity. Therefore, I willnot engage in any activity beyond my capabilities that may cause endangerment.
  • I understand that, if I am uncertain how to operate anyequipment, it is my responsibility to get clarification from staff before I climb.
  • I understand that Birkenhead Pool and Leisure Centre staff reserve the right to remove me from belaying if my technique does not meet facility standard.
  • I certify that I am in good health, both physically and mentally fit to be able to safely participate in this activity. I agree to notify the staff of Birkenhead Pool and Leisure Centre of any health or medical concerns that may affect the safety of my participation in this activity.
  • I agree to bring any concerns or unusual significant hazards I observe to the attention of the staff on the day.
  • I understand that I must be at least 8 years old to belay on the rock-climbing wall.
  • I understand that I must be 14 years or older to climb without direct supervision by a parent/guardian, unless I am participating in a supervised activity (Birkenhead Pool and Leisure Centre climbing class or EOTC programme only).
  • As a supervising parent/guardian, I additionally acknowledge that I am personally responsible for the health, safety and welfareof my child/youngperson while climbingand the role of Birkenhead Pool and Leisure Centre is to support me in this.
  • I have read, understood and agree to abide by the facility and activity rules outlined by the Birkenhead Pool and Leisure Centre. I understand that failure to do so only increases the risk of my safety and others, and I may be removed from the premises as a result.

Birkenhead Pool and Leisure Centre Climbing Wall rules

  1. Report to reception on each visit before you climb.
  2. Respect other users of this facility.
  3. Belayers and climbers must always be harnessed and clipped.
  4. All equipment must be used in the correct way as shown by the staff of this facility during the safety briefing.
  5. Do not climb up the belay ropes, or support structures.
  6. The mats are there to lessen your impact in case of a fall and therefore must not be used for jumping or gymnastics activities
  7. All karabiners attached to top rope climbers must be clipped back to one another upon finishing climb.
  8. The belayer must always ensure the rope is tensioned for the climber while climbing.
  9. When bouldering climbers must receive orientation by a staff member.
  10. Ensure both karabiners are clipped to the climber’s harness.
  11. Footwear must be worn on all climbing walls.
  12. Do not run in the climbing area.
  13. You must be 8 years old or over to belay.
  14. Lead climbers must clip onto all quickdraws on the route you are climbing.

Parent/guardian for child/ren under 14:

  • As a parent/guardian I hereby declare I am 14 years of age or older and have read, understood and accept the aforementioned conditions on behalf of my child/ren/young person.
  • Asa parent/guardian I additionally acknowledge that Birkenhead Pool and Leisure Centre is not responsible for the health, safety or welfare of my child/ren/young person.

We may take general photographs or videos of the facilities at any time. If you or your child appear in those photographs or videos, you agree that we may use them for marketing and promotional purposes and that you have no rights or copyright in the material. You release Auckland Council, the photographer or filmmaker, and each of their licensees and assignees, from any and all claims and demands in connection with the material or its future use.
We will seek your consent before using any photos or videos in which you or your child are clearly recognisable.
You must get the permission of the staff member in charge before taking photos or videos of anyone outside of your own party.

Today's Date: November 26, 2020

First Participant's Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email*

Confirm Email*
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Address

Address Line 1: (Street address, P.O. box, company name, c/o) *

Address Line 2: (Apartment, suite, unit, building, floor, etc.)

Country: *

City: *
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 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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