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Blockhouse Bouldering Gym 

3 ½ East 1st Street, The Plains, OH 45780 

 

Participation Agreement, Release and Acknowledgement of Risk 

Facility Orientation & Rules

Facility Rules & Bouldering Orientation

Inherent Risks of Bouldering

  • Holds can spin or break
  • All falls are ground falls
  • Pads are a mitigation measure only- No guarantee of safety or injury prevention
  • Falls may result in injury especially with improper falling technique

Falling Technique

  • Try to land on your feet with knees slightly bent, lean backwards and roll onto back with arms tucked in to chest
  • Don’t land with knees locked
  • Don’t put arms in front or behind to brace your fall- this is common cause of wrist injury- tuck arms into chest- "give yourself a hug"
  • Practice falling by starting with low falls then working your way higher up the wall
  • Always down climb when able/possible

Bouldering Rules

  • Colored difficulty scale is posted
  • No grabbing top of wall or touching ceiling rafters or lights

Awareness of Surroundings

  • Make sure landing area is clear before climbing or falling
  • Note the location of other climbers

Spotting Review

  • Purpose of spotting is to prevent head/neck injury
  • How to spot 
  • When to spot
  • When a climber makes a committing or jumping move near the top of the wall
  • When a climber is in a precarious position such as a foot at or above head level

Facility Rules – Please…

  • No running
  • No food or drink on padded areas
  • Do not wear climbing shoes in restroom
  • Wipe down fitness equipment after use
  • Children aged 12 & under must be supervised by adult
  • Ask questions if you are unsure about anything

As a new climber, I understand that I require orientation before participating in climbing activities in this facility. I understand that if I need additional assistance, orientation, instruction, training or assessment during my participation at the climbing facility at any future time that it is my responsibility to seek such assistance from the climbing gym staff prior to participation. My signature indicates that I understand the above information and that the climbing gym staff has presented this information to me. 

Facility Rules Reviewed

Facility Tour

Posted Warnings

Climbing Rating System Explained

Policies For Minors Reviewed

Bouldering Rules Explained

WARNING: There are significant elements of risk in any adventure, sport or activity associated with a rock gym, climbing wall, bouldering area and incidental weight and fitness training regimens and equipment (referred to herein as "acitvity"). 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 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 this activity, but we do think it is important for you to know in advance what to expect and to be informed of inherent risks. 

 

ACKNOWLEDGEMENT OF RISKS: I AM AWARE THAT ROCK CLIMBING (and other activities described herein) IS AN INHERENTLY DANGEROUS ACTIVITY, and a recreational sporting activity that carries with it significant risks, including but not limited to: 1) Falls onto the ground or other climbers; 2) Risk associated with climbing or down climbing; 3) My physical strength, coordination, sense of balance, and ability to follow or give directions including while climbing, lifting or spotting; 4) Fatigue, chill and/or dizziness, which may diminish reaction time and increase the risk of an accident; and 5) The actions of other participants (including negligence and risks from falling climbers); and 6) Risks associated with engaging in a non-climbing activity. 

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

 

EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: In recognition of inherent risks of the activity which I and/or any minor children for which I am responsible, will engage in, I confirm that I am (we are) physically and mentally capable of participting in the activity and/or using equipment. I/We participate willingly and voluntarily and assume full responsibility for personal injury, accidents or illness (including death), and any related expenses. I also assume responsibility for damage to or loss of my/our personal property. I also assume risk for accidents or injury caused by negligence of my spotter whether such negligence is comparative or contributory. 

I assume the risks(s) of personal injury, accidents and/or illness, including but not limted to sprains, torn muscles and/or ligaments; fractured or broken bones; eye damage; cuts, wounds, scrapes, abrasions, and/or contusions; dehydration; oxygen shortage (anoxia); head, neck and/or spinal injuries; insect bite or allergic reaction; shock, paralysis, and/or death. 

I acknowledge that this waiver does not relate to an essential service, but merely a voluntary recreational activity - climbing. I acknowledge that I have the option of not signing this waiver and not climbing at this particular facility. 

 

COVENANT OF GOOD FAITH: I recognize that you, as a provider of services, will operate under a covenant of good faith and fair dealing, but that you may find it necessary to terminate an activity due to forces of nature, medical necessities or problems in the group; and/or refuse or terminate, the participation of any person you judge to be incapable of meeting the rigors or requirements of participating in the activity. I accept your right to take such actions for the safety of myself and/or other participants. I acknowledge that no guarantees have been made with respect to climbing objectives.

 

AUTHORIZATION: I hereby authorize Southeast Ohio Recreation LLC, Blockhouse Bouldering Gym, and it's employees to provide for or arrange for provision of (in each case, in its sole discretion, without undertaking a duty herein to do so) any medical treatment deemed necessary in the event of any injury or illness while participating in the activity. I either have appropriate insurance or, in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my/our behalf. 

 

RELEASE: In consideration of services or property provided, I, for myself and any minor children for which I am parent, guardian, or otherwise responsible, and any heirs, personal representatives or assigns, do hereby discharge, release and hold harmless:

Southeast Ohio Recreation LLC, Blockhouse Bouldering Gym

its principals, directors, officers, agents, owners, employees and volunteers, and each and every land owner, municipal and/or governmental agency upon whose property an activity is conducted, from all liability and waive any claim for injury or damage arising from the activities described herein, or any cause whatsoever, including negligence (but excepting that which is the result of gross negligence). 

 

COVID-19 ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY: I further acknowledge that the novel coronavirus (COVID-19) infections have been confirmed throughout the United States, including cases in Ohio and all other states. In accordance with the most recent guidance and protocols issued by the World Health Organization (WHO), the Centers for Disease Control (CDC), the Governor of the State of Ohio, the Ohio Department of Health (ODH), and other applicable local health authorities (Public Health Agencies) for slowing the transmission of COVID-19, I hereby agree, represent, and warrant that neither I nor any minor child of whom I am parent or guardian shall visit or utilize this facility, its services or programs, if any such persons (i) experience symptoms of COVID-19, including, without limitation to, fever or chills, cough, mental or physical fatigue, muscle or body aches, headache, loss of sensations of smell or taste, sore throat, congestion or runny nose, nausea, vomiting or diarrhea or shortness of breath or difficulty breathing, (ii) has a suspected or diagnosed/confirmed case of COVID-19 and/or (iii) has been exposed to anyone with a suspected or diagnosed/confirmed case of COVID-19. 

I further acknowledge that Blockhouse Bouldering Gym has taken certain steps to implement recommended guidance and protocols issued by Public Health Agencies for slowing the transmission of COVID-19. I acknowledge and agree that Blockhouse Bouldering Gym may revise its procedure at any time based on updated recommended guidance and protocols issued by Public Health Agencies and further agree to comply with Blockhouse Bouldering Gym's procedures prior to and during utilization of the facilities, services and/or programs of Blockhouse Bouldering Gym. I further acknowledge and agree that, due to the nature of the facilities, services and programs offered by Blockhouse Bouldering Gym, social/physical distancing of 6 feet per person in hands-on training, climbing, or exercise and educational settings may not always be possible. I fully understand and appreciate both the known and potential dangers of utilizing the facilities, services, and/or programs of Blockhouse Bouldering Gym and acknowledge that use thereof by me and/or any minor child of whom I am parent or guardian may, despite Blockhouse Bouldering Gym's reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability and/or death to me, any minor child of whom I am parent or guardian and/or persons who are exposed to COVID-19 as a result of contact with me or my contact with them. 

 

I FURTHER ACKNOWLEDGE THAT SECTION 2(A) OF AM. SUB. H. B. NO. 606, ENACTED BY THE OHIO GENERAL ASSEMBY AND SIGNED INTO LAW BY OHIO GOVERNOR DEWINE ON SEPTEMBER 14, 2020, PROVIDES THAT No civil action for damages, injury, death or loss to person or property shall be brought against any person if the cause of action on while the civil action is based, in whole or in part, is that the injury, death or loss to person or property is caused by the exposure to, or the transmission or contraction of MERS-CoV [the coronavirus that causes middle east respiratory syndrome], SARS-CoV [the coronavirus that causes severe acute respiratory syndrome], or SARS-CoV-2 [the novel coronavirus that causes COVID-19], or any mutation thereof, unless it is established that the exposure to, or the transmission or contraction of, any of those viruses or mutations was by reckless conduct or intentional misconduct or willful or wanton misconduct on the part of the person against whom the action is brought. 

 

I HAVE READ THIS AGREEMENT, FULLY UDNERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OR ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT. THIS AGREEMENT AND RELEASE SHALL REMAIN IN FULL LEGAL FORCE AND EFFECT UNLESS AND UNTIL I NOTIFY BLOCKHOUSE BOULDERING GYM IN WRITING THAT I INTEND TO VOID THE AGREEMENT, AT WHICH TIME I SHALL BE PROHIBITED FROM TAKING PART IN ANY ACTIVITIES AT THIS FACILITY.

October 6, 2022

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*
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?
Friend/Family member/Word of mouth
Google/Internet search
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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 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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