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Health History and Emergency Treatment Authorization

(RockPoint LLC, 1200 Constitution Ave, Littleton, MA 01460 / 978-990-7625 / www.MetroRock.com)


I hereby grant MetroRock and its agent’s full authority to take whatever action they deem necessary regarding my child’s health in the case of an emergency where I am unable to make a timely decision. I fully release MetroRock and its agent’s from any liability in connection with those decisions. I grant permission for emergency treatment by a private physician and/or hospital or emergency health care facility staff, under the same circumstances as below, if needed. Any such action will be taken in my best interest. 

October 10, 2026

Please select who will be participating...
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First Participant Name
First Name*
Last Name*
Phone*
First Participant Date of Birth*
Date of Birth
First Participant Signature*
Participant Insurance Information
Medical Insurance Company *
Medical Insurance Policy Number *
Name of Insured *
Primary Care Doctor *
Primary Care Doctor Phone *
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:*
In case of emergency while at MetroRock Climbing Camp, please contact:

In case of emergency while attending MetroRock Climbing Camp, please contact:

Contact Name
Contact Phone Number
Street Address *
City *
State *
Zip Code *
Relationship to Participant *

Alternative Contact

Alternative Contact Name
Alternative Contact Phone
Participant Medical Information
Has this child ever broken a bone?*
Yes
No

If "yes", please explain.
Does this child have diabetes?*
Yes
No

If "yes", please explain. *
Does this child have asthma?*
Yes
No

If "yes", please explain.
Does this child suffer from seizures?*
Yes
No

If "yes", please explain.
Date of last seizure
Has this child been diagnosed with a heart murmur?*
Yes
No

If "yes", please explain.
Does this child suffer from joint pain or injury?*
Yes
No

If "yes", please explain.
Has this child ever been dizzy during or after exercise?*
Yes
No

If "yes", please explain.
Does this child have emotional difficulties for which help was sought?*
Yes
No

If "yes", please explain.
Has this child had back problems?*
Yes
No

If "yes", please explain.
Has this child ever felt chest pain during exercise?*
Yes
No

If "yes", please explain.
Does this child wear glasses or contact lenses?*
Yes
No

If "yes", please explain.
Has this child ever been knocked unconscious?*
Yes
No

If "yes", please explain.
Has this child ever been hospitalized?*
Yes
No

If "yes", please explain.
Has this child ever had surgery?*
Yes
No

If "yes", please explain.
Is this child currently taking and medications, prescribed or otherwise?*
Yes
No

Please list all medications and dosed below.
Does your child have any known allergies or dietary restrictions (food, medications, bees, insects, other)?*
Yes
No

Please detail below:
Does this child have any conditions that require medication, treatment, or special restrictions or considerations while at MetroRock?*
Yes
No

If "yes", please explain.
Parent or Guardian's Email Address
Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.

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*
Last Name*
Relationship*
Phone*
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 Date of Birth*
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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