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WARNING: 


Climbing is an activity that involves risks. I am aware that by participating in the activities of Rose Bloc Inc. climbing center, I expose myself to these risks. 


I agree that it is necessary for me to participate in an introduction session with a staff member on my first visit to the climbing gym.


ACKNOWLEDGEMENT OF RISKS:


I acknowledge that the following describes some, not all, of the risks related to indoor climbing and fitness training:


  • injuries associated with falls or other movements, (EX: sprain, strain, fracture, etc.);
  • injuries, abrasions or cuts with blunt or sharp objects, (EX: holds, equipment, walls, etc.)
  • injuries associated with the misuse of equipment or installation, or failure of personal protective equipment;
  • injuries resulting from accidental or unintentional contact between individuals;
  • injuries resulting from negligent behavior on your part or on the part of other users;
  • neurodegenerative injuries resulting from a fall or an impact.


CHILD CLIMBERS AND VISITORS: 


I affirm that the child for whom I am signing the form is my biological son/daughter or that I am the legal guardian. 


I agree to respect the rules and regulations that I have read and understand when I am with a child at Rose Bloc Inc. climbing center as a climber or as an attendant.


Accompanying a minor: I agree that the parent or legal guardian has given me custody of the minor I am accompanying and that the parent or legal guardian agrees that the minor participates in activities at Rose Bloc Inc. climbing center.


INTRODUCTION AND FALL TESTS: 


I understand that, for the safety of all, I must participate in a safety introduction session before beginning my activity.


I understand that I must respect my body and my abilities when choosing the height at which I climb.


I CERTIFY THAT:


  • I am in good physical condition and have no personal health issues that prevent me from participating in climbing activities;
  • I understand and I agree to abide by the rules and regulations of the Rose Bloc Inc. climbing center, a copy of which is posted in the climbing center; 
  • I am aware of the risks inherent to climbing;
  • I accept to undertake the activity with full knowledge of these risks;
  • I agree to play an active role in managing these risks;
  • I have been informed that Rose Bloc Inc. climbing center reserves the right to exclude any person who represents a risk to himself or herself or to others, without refund;
  • I agree to the use of photos and videos taken during the activity for promotional purposes;
  • I certify that I am not under the influence of any substance (drugs and/or alcohol) and I will not consume any during all climbing activities (present and future).


I, the undersigned, hereby waive any and all claims, as well as any and all lawsuits for damages to my property and equipment.


"I acknowledge that I have read and understand the above acknowledgement and acceptance of risks and responsibilities, I freely and fully agree to assume all of the above risks and hazards and I agree to abide by the rules and regulations of Rose Bloc Inc. climbing center."


September 28th, 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*
Parent or Guardian's Email Address

Email
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A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last 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.


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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