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RISK ACCEPTANCE FORM - CAFÉ BLOC

WARNING: Any activity or sport associated with a bouldering area, as well as with equipment and related physical conditioning regimes (hereinafter called "activities"), involves elements of considerable risk. Although we have taken responsible steps to provide you with appropriate instructions and / or qualified instructors to enable you to enjoy an activity for which you may not be skilled, we would like to remind you that this activity does is not without risks. Certain risks cannot be eliminated without destroying the uniqueness of the activity. The elements that make this activity unique can cause the loss or damage of your equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. We don't want to scare you or reduce your enthusiasm for the activity, but we believe it is important that you know ahead of time what to expect and that you are warned of the inherent risks.

Risk recognition

I acknowledge that the following describe some, but not all, of the risks of indoor climbing and physical training:

1. Painful slipping, tripping, falling, or crashing when using facilities or equipment, climbing walls, landing pits, floors under climbing areas, training areas, sanitary facilities or steps;

2. Misuse of equipment or facilities, or equipment failures;

3. Unexpected falls due to improper positioning, a poorly performed parade or due to an unexpected loss of control;

4. My health, physical strength, coordination, sense of balance and ability to follow or give directions during climbing or training may not be enough to allow me to practice in complete safety indoor climbing sport;

5. Fatigue, chills and / or dizziness, which can reduce my / our reaction time and increase the risk of an accident;

6. Abrasions caused by equipment or structures;

7. The presence, actions or falls of other participants.

I understand that the description of these risks is not complete and that other unknown or unforeseen risks may lead to injury, illness or death.

I also undertake to play an active role in the management of these risks, by adopting a preventive attitude towards me, towards those who accompany me as well as towards other people who participate in activities.

Health and physical condition

I certify that I am in good physical condition and that I have no personal health problems preventing me from participating in the activities of the rock climbing gym Café Bloc.

I agree to mention any physical or mental condition that could affect my safety or that of others.

Alcohol Comsumption

I understand and accept that it is strictly forbidden at Café Bloc to do
bouldering or any other form of training under the influence of alcohol and
that the consumption of alcohol at Café Bloc is authorized only in the café
area. Therefore, I understand also that it is forbidden to consume alcohol in
the climbing areas, on the mattresses and in the training area.

Furthermore, I understand that it is strictly forbidden to use drugs or be under the
influence of drugs at Café Bloc.

Risk acceptance

I accept the risks of bodily harm, accidents and / or diseases, including in particular but not limited to sprains, muscle and / or ligament tears, cracks or fractures, eye conditions, cuts, injuries, scrapes, abrasions and / or bruises, dehydration, lack of oxygen (anoxia), exposure and / or altitude sickness, trauma to the head, neck and / or spine , lung problems, nervous shock, paralysis and / or death.

I ASSUME FULL RESPONSIBILITY FOR THE CHOICE OF A PERSON RESPONSIBLE FOR PREVENTING SUCH RISKS.

Commitment to comply with rules and regulations

I confirm that I understand and agree to abide by the rules and regulations of the rock climbing gym Café Bloc, a copy of which is posted in the gym. (A printed copy of the regulations is available on request).

The rock climbing gym Café Bloc and its representatives reserve the right to refuse or suspend the right of access to the center to any climber who demonstrates a dangerous attitude towards indoor climbing safety at the rock climbing gym Café Bloc, or who does not respect the rules and regulations of the rock climbing gym Café Bloc.

Wearing a helmet

I understand that wearing a climbing helmet can reduce the risk of head injury and I am personally responsible for my decision whether or not to wear a helmet. It is my responsibility to provide my own helmet.

Children climbers and visitors

I affirm that the child for whom I sign the form is indeed my child, my biological child or that I am the legal guardian. I agree to abide by the rules that I have read and understood when I am with a child at the rock climbing gym Café Bloc as a climber or guide.

Photographs and advertising material

I authorize the Café Bloc Climbing Center to use the participant's photographs and video material for advertising purposes without any compensation whatsoever.

Orientation and fall tests

I understand that, for everyone's safety, I must participate in a safety orientation before starting my activity.

Affix your initials

I understand that I must respect my body and my skills when choosing the height to which I climb.

 

Affix your initials

''I acknowledge having read and understood the recognition and acceptance of the above risks and responsibilities, I FREELY AND FULLY ACCEPT TO ASSUME ALL THE RISKS AND DANGERS MENTIONED ABOVE AND I COMMIT TO RESPECT THE RULES AND REGULATIONS OF THE ROCK CLIMBING GYM CAFÉ BLOC.''

Dated: September 18, 2020 

 

First Participant's Name

First Name*

Last Name*
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*
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*
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*
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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