San Juan College Health and Human Performance Center Indoor Climbing Wall
Assumption of Risk and Release of Liability Form (Revised March 2016)
This form covers a summer 2016 indoor climbing class through Kids Kollege. Any patron who chooses not to sign this document will not be permitted to
participate in any climbing related activities. The participant information below will be reviewed by climbing wall staff and kept confidential.
Participant Name: ______________________________________________________________________________________________________________
Date of Birth:
Current level of
physical activity:
Very high
(Circle one)
Do you have any pre-existing
YES
medical/physical conditions,
disabilities (temporary or
permanent)? If yes, identify and
explain:
Do you have high blood pressure? If YES
yes, are you taking medication?
Please list.
Do you have any type of heart
YES
condition, or is there a history of
heart conditions in your family? If
yes, identify and explain:
Are you currently taking medication YES
(prescribed or otherwise, e.g. cold
medicine)? If yes, state what you are
taking and what condition it is for.
Do you have any allergies, reactions YES
to medication, or any other medical
limitations? If yes, identify and
explain:
Gender: M F
High
Height:
Weight:
Moderate
Low
NO
NO
NO
NO
NO
Climbing is a complex activity. The risk of injury for activities involved in using the climbing wall is significant. Climbing and belaying terrain always creates
potential for an accident. Professional climbing instructors reduce risk substantially but can never eliminate risk. Inherent risks of climbing include but are not limited
to: Injury from falling up to 35 feet and impact against the wall or landing surface; injury in the form of cuts, bruises, abrasions, muscle or tendon strain; rope burns;
failure to follow safety policies and procedures or follow directions from Indoor Climbing Wall staff; the presence, actions or falls of other patrons; misuse of
equipment or facilities in the climbing area such as hanging on or swinging from ropes; injury caused by belayer (climbing partner) negligence; excessive traversing too
far to the side resulting in a pendulum fall; and failure to remove hazardous jewelry or other sharp objects. The dangers and risks of participation could include, but is
not limited to: death, serious neck or spinal injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints,
ligaments, muscles, tendons, and other aspects of the muscular-skeletal system and serious injury or impairment to other aspects of my body, general health and wellbeing. This risk includes but is not limited to: falling off or from the Indoor Climbing Wall and hitting the floor, wall faces, people or any other equipment used in
climbing, whether permanently or temporarily in place; rope abrasion and entanglement; injuries resulting from falling climbers, dropped items or broken holds; failure
of ropes, knots, belays, slings, harnesses, climbing holds, anchor points or any other part of the Indoor Climbing Wall.
Our climbing facility has risk management procedures and guidelines in place to mitigate risk and follows the principles of the American Mountain Guides Association
Climbing Instructor Program. Climbing wall staff members can give a facility orientation to demonstrate what types of climbing are permitted in the facility and where
it is permitted. Accepted bouldering height is clearly marked in the facility. Every patron must be aware of falling and swinging climbers and must avoid standing in
areas where they could become injured as the result of an impact. Objective hazards include bolts, quick-draws, walls, and tripping hazards. It is possible for holds to
spin and potentially break. In climbing facilities and programs, the well-being of one patron is eventually entrusted to the skills of another. Demonstrated competence
and the successful completion of a top-rope belay test is required before a patron is allowed to handle this responsibility.
Agreement:
1. I understand and assume ALL risks associated with climbing activities whether specified or not. In recognition of the inherent risks of the climbing activity which I,
and any minor children for which I am responsible, will engage in, I confirm that I am (we are) physically and mentally capable of participating in the climbing activity
and/or using the equipment. I participate willingly and voluntarily and I assume full responsibility for personal injury, accidents or illness, including death.
2. I expressly agree and promise to accept and assume all of the risks existing in climbing activities. My participation in this activity is purely voluntary, no one is
forcing me to participate, and I elect to participate in spite of the risks.
3. I hereby voluntarily release, forever discharge, and agree to hold harmless and indemnify San Juan College from any and all liability, claims, demands, actions or
rights of action, which are related to, arise out of, or are in any way connected with my participation in climbing activities, including those allegedly attributable to the
negligent acts or omissions of San Juan College.
4. I acknowledge that the use of a protective helmet could prevent brain damage or death in the event of an accident. Against the advice of San Juan College, I am
refusing to wear a protective helmet for use on the Indoor Climbing Wall and take full responsibility for my own decision in refusing this critical safety precaution. If I
choose to wear a helmet at any time, it is my responsibility to request one.
5. I hereby certify that I am in good health and I know of no medical reason why I am not able to participate in activities at the Indoor Climbing Wall. I have informed
the San Juan College Indoor Climbing Wall Staff of any physical or medical condition that might expose me to an unusual risk of harm. I hereby consent to first aid,
emergency medical care and if necessary admission to a hospital when necessary for administering such care, for treatment for injuries that I may sustain while
participating in the activity.
6. I accept and will abide by the San Juan College Indoor Climbing Wall policies. I accept and will abide by the behavioral expectations of the activity and the policies
and procedures of San Juan College.
By signing this document below, I acknowledge that if I am injured during the course of my participation on the indoor climbing wall, I hold San Juan College harmless
for any and all injuries. I assume all risks associated with my participation in this activity. 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.
____________________________________________________________________________________________
Participant (Child’s) Name PRINTED
Date
____________________________________________________________________________________________
Address
Age and Date of Birth
______________________________________________________________________________________________________________________
SIGNATURE of Parent or Legal Guardian (if participant is under 18)
Parent or Legal Guardian Name PRINTED
Signing authority for minors under the age of 18 can be: A parent or a legal guardian appointed by the courts. Signing authority cannot be other
relatives including brothers, sisters, and grandparents unless they are appointed by the courts. Signing authority cannot be friends, neighbors, school
teachers, or youth leaders.
Emergency Contact Information:
Person to Contact in Case of Emergency
White copy-HHPC
Relationship to Child Date
Yellow copy-Kids Kollege
Phone Number
Pink copy-Parent/Guardian