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DAY CAMP ACKNOWLEDGEMENT &
ASSUMPTION OF RISK

WARNING
There are significant elements of risk in any sport or activity associated with rock climbing or bouldering area, incidental fitness training regimens and equipment (referred to herein as ‘Activity’). 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 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 with bouldering wall texture and hold's texture.
7. The presence, actions or falls of other participants.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 of FREDERICTON BOULDERING CO-OP.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 orbroken 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.

AGREEMENT TO ABIDE BY THE RULES AND REGULATIONS
I agree to abide by the rules and regulations of FREDERICTON BOULDERING CO-OP, which are posted on the bulletin board on the floor of the gym. A written copy of the rules and regulations will be made available on request. FREDERICTON BOULDERING CO-OP reserves the right to refuse access to any climber who does not conform with rules and regulations or who demonstrates an unsafe attitude toward safety in indoor climbing while at FREDERICTON BOULDERING CO-OP.



AUTHORIZATION FOR TRAVEL
I give permission for my child to leave the premises of FREDERICTON BOULDERING CO-OP to participate in trips. I give permission to the staff of FREDERICTON BOULDERING CO-OP to take my child to all scheduled trip locations for the FREDERICTON BOULDERING CO-OP’s program. I understand that my child will be escorted and supervised by the staff of FREDERICTON BOULDERING CO-OP while participating in these activities. In the event of an injury requiring medical attention, I hereby grant permission to the supervising staff (including volunteers) to attend to my child. If the injury warrants further medical attention, I expect every effort will be made to contact me to receive my specific authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given. In addition, I hereby give my permission to the supervising staff (including volunteers) to take my child to the physician, dentist, or to the hospital if an accident or serious illness occurs on the trip and I cannot be located. I will not hold FREDERICTON BOULDERING CO-OP responsible for any injuries that may occur to my child while in their care.

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

“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
FREDERICTON BOULDERING CO-OP.”

Today's Date: August 4, 2020

First Participant's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle 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*
Travelling Home & Transportation Consents
I give consent for my child to travel to and from school or home unsupervised. If my child does not arrive at the facility within the predetermined time period, missing child procedures will be initiated to find them. I will advise the facility when my child is absent.*
No
Yes
N/A
Consent for transportation to and from school (After School Program Only)*
No
Yes
N/A
Photo & Media Release
I hereby give FREDERICTON BOULDERING CO-OP and its partners and affiliates consent to use and reproduce my child's name/image for promotional purposes related to FREDERICTON BOULDERING CO-OP and/or external partners. My child's first name (unless otherwise authorized)/image may be published or used in newspapers, promotional videos, program brochures, posters, on World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by FREDERICTON BOULDERING CO-OP. I release FREDERICTON BOULDERING CO-OP from any and all claims, of any nature, based on any uses of the above. *
Yes
No
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 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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