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Adult Novice: Supervisor Acknowledgment of Risk form

(This form is to be completed by a registered Adult Stronghold customer as well as the Adult Novice climber)



Participation Statement

“All climbing and bouldering activities have a risk of serious injury or death. Participants must be aware of and accept that even if they follow all good practice there may still be the risk of accident and injury. It is the responsibility of the participant to adhere to the conditions of use."

Before participating in climbing or bouldering at the Stronghold Climbing Centre you must have watched the Induction Video.

It is important that you understand this document. There is inherent risk involved with climbing centres and associated activities. By signing this form you are stating you understand that these risks cannot be completely removed. If you do not understand any of the terminology or content, ask a member of staff to clarify.


STRONGHOLD SUPERVISION POLICY - ADULT

Every adult wanting to supervise a novice adult climbing at Stronghold will have to be registered as an Unsupervised Adult, have watched the safety video and read, accepted and agreed to abide by the Terms and Conditions of use.

The Adult Supervisor will also need to register to supervise by signing this Stronghold Supervisor Acknowledgment of Risk form, answering the supervisory safety questions and reading our supervisor policy and rules. If you are unable to answer the supervisory safety questions, you will have to book an Adult Induction before being allowed to supervise.


Today's Date: January 28, 2023





First Novice Participant Name

First Name*

Middle Name

Last Name*

Phone*
First Novice Participant Date of Birth*
First Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
First Novice Participant Signature*
Second Novice Participant Name

First Name*

Middle Name

Last Name*
Second Novice Participant Date of Birth*
Second Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Third Novice Participant Name

First Name*

Middle Name

Last Name*
Third Novice Participant Date of Birth*
Third Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Fourth Novice Participant Name

First Name*

Middle Name

Last Name*
Fourth Novice Participant Date of Birth*
Fourth Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Fifth Novice Participant Name

First Name*

Middle Name

Last Name*
Fifth Novice Participant Date of Birth*
Fifth Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Sixth Novice Participant Name

First Name*

Middle Name

Last Name*
Sixth Novice Participant Date of Birth*
Sixth Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Seventh Novice Participant Name

First Name*

Middle Name

Last Name*
Seventh Novice Participant Date of Birth*
Seventh Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Eighth Novice Participant Name

First Name*

Middle Name

Last Name*
Eighth Novice Participant Date of Birth*
Eighth Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Ninth Novice Participant Name

First Name*

Middle Name

Last Name*
Ninth Novice Participant Date of Birth*
Ninth Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Tenth Novice Participant Name

First Name*

Middle Name

Last Name*
Tenth Novice Participant Date of Birth*
Tenth Novice Participant Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information & news about Stronghold Climbing Centres by e-mail.
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:*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Adult Supervisor To Complete
1) Do you certify that to the best of your knowledge that the Adult Novice participant named above does not suffer from any medical conditions which might be adversely affected by participation in climbing activities at Stronghold?*
No
Yes
2) Are you aware you are fully responsible for the Novice Adults, and therefore must be in full control at all times?*
No
Yes
3) Have you read, understood and agree to abide by the Stronghold supervision policy and rules?*
No
Yes
4) Do you understand that you must be registered to climb, watched the SAFETY VIDEO and read and understood the Terms & Conditions of use to supervise at Stronghold?*
No
Yes
5) Do you understand that failure to supervise properly may result in your climbing session being stopped?*
No
Yes
6) Do you agree to abide by this document and the conditions of use of the climbing centre?*
No
Yes
7) Declaration of fact: I also confirm that the above information is correct and if any information changes I will notify the centre.*
No
Yes
8) I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS.*
No
Yes
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Agreement
1) Have you read, understood and agree to abide by the Stronghold supervision policy and rules? *
No
Yes
2) Liability: This agreement releases Stronghold Climbing Centre from all liability relating to injuries that may occur during any activities on location. By signing this document you are signing to say you understand this fact.*
No
Yes
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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