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Climbing Club at the University of Illinois at Urbana-Champaign 

Agreement to Participate and Release Form

I am aware participation and membership in the Climbing Club including, but not limited to rock climbing, mountaineering, and associated activities or any other activity organized by or including any members of the Climbing Club or using equipment available through the Climbing Club can be dangerous, involving MANY RISKS OF INJURY. I have voluntarily chosen to participate in the Climbing Club at UIUC knowing that it brings risks of death, injury, damage or loss to myself and my property, from such events including, but not limited to, falls, rock falls, avalanches, lightning, river crossings, hypothermia, frostbite, heat or cold injuries, bites and stings, and accidents traveling to and from activity sites. I understand that equipment may fail, and such failure could contribute to my injury or death. My participation in these activities is completely voluntary and is undertaken in spite of the hazards and risks involved. I understand that the dangers and risks of participation and membership include, but are not limited to death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system and serious injury or impairment to other aspects of my body, general health, and well-being. I understand that the dangers and risks of participation and membership in the Climbing Club at UIUC may result not only in serious injury, but in a serious impairment of my future abilities to earn a living, to engage in other business, social and recreational activities and generally to enjoy life. Because of the dangers of participation and membership, I recognize the importance of following rules and regulations established by the University of Illinois and/or the Climbing Club at UIUC, and agree to obey such instructions. I acknowledge that I am in good physical condition and do not know of any condition or reason that I should not be able to participate in rock climbing, mountaineering, and associated activities or any other activity organized by or including any members of the Climbing Club or using equipment available through the Climbing Club. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, and assume full responsibility for my participation. I recognize and acknowledge that the Climbing Club at UIUC, as a registered organization of the University of Illinois at Urbana-Champaign, does NOT carry special health insurance, other than such medical and/or hospital services as are normally provided for students of the University of Illinois by the Student Health center, that would provide such special insurance coverage for me in the event I should sustain an accidental injury while participation in rock climbing, mountaineering, and associated activities or any other activity organized by or including any members of the Climbing Club at UIUC or suing equipment available through the Climbing Club at UIUC. I understand that I am solely responsible for assessing whether my skills, equipment, and level of physical and mental fitness are adequate for participation and membership in the Climbing Club at UIUC or using equipment available through the Climbing Club at UIUC. I represent that I have full knowledge of the skills, equipment and level of physical and mental fitness necessary for participation and membership in the Climbing Club at UIUC and that I meet or exceed these requirements. I understand that participation and membership in the Climbing Club at UIUC involves activities in rugged terrain in all extremes of weather, and I may be very far removed from any professional or medical services. I understand that rescues may take more than 24 hours and all medical and rescue costs are my responsibility. I understand the importance of obtaining sufficient medical and accident insurance before participation in the Climbing Club at UIUC. I understand the risks involved in this activity and I am voluntarily participating in rock climbing, mountaineering, and associated activities or any other activity organized by or associated with participating in the Climbing Club at UIUC or using equipment available through the Climbing Club at UIUC. By my signature below, I hereby recognize and assume all risks associated with participating in the Climbing Club at UIUC including, but not limited to, rock climbing, mountaineering, and associated activities or any other activity organized by or including any members of the Climbing Club at UIUC or using equipment available through the Climbing Club at UIUC and agree to hold the University of Illinois, its employees, agents, representatives and volunteers, the Climbing Club at UIUC, its officers, officials, members, and participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct a Climbing Club at UIUC activity harmless from any and all obligations, liabilities, claims, demands, costs, and expenses, including attorney’s fees, or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to advertisers, and, if applicable, owners and lessors of premises used to conduct a Climbing Club activity may incur as a consequence of any legal action arising out of injury to myself or injury to someone else as a result of my conduct. I state that I am currently covered by medical insurance for any injuries that may occur to me while participating in the Climbing Club at UIUC activities. I understand that the Climbing Club at UIUC, its officers, officials, members, and participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct a Climbing Club at UIUC activity make no assurances of the accuracy or safety of any equipment, instruction, advice or facilities provided by parties including, but not limited to, the Climbing Club at UIUC, its officers officials, members, participants, and individuals or institutions encountered through Climbing Club at UIUC activities and events. I further state that I understand and fulfill all requirements of the University of Illinois for participation in a registered organization. The terms hereof serve forever as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and for all members of my family. In signing this Release, I acknowledge and represent that I have read it, understand it, and signed it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from this Release have been made.

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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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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(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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