Loading...

Bloc Shop Climbing Gym Risk Agreement

WARNING : All activities or sports associated with an indoor bouldering facility and with training equipment and training programs (herein reffered to as « activity ») present elements of considerable risk. Although we have taken serious measures to provide you with appropriate instructions for you to practice an activity with which you might not be completely familiar, we wish to remind you that this activity is not risk free. Indeed, some risks cannot be eliminated without destroying the unique character of the activity. Elements that contribute to making this activity unique could cause loss or damage of your material, accidental injury, sickness or in extreme cases, permanent trauma or death. We do not wish to scare you or reduce your enthusiasm towards the activity but we believe it important that you know beforehad what is involved and make you aware of inherent risks.

RISK AKNOWLEDGEMENT

I UNDERSTAND THAT THE FOLLOWING ELEMENTS DESCRIBE SOME AND NOT ALL THE RISKS OF INDOOR CLIMBING, AND OF PHYSICAL TRAINING:

1. Sliding, tripping falling or colapsing painfully while using the installations, material, climbing walls, reception mattresses, floors, training area, change rooms or stairs;

2. Incorrect usage of the material, installations, or equipment failure;

3. Suprise falls due to an incorrect position, incorrect spotting or an ususpected loss of controll;

4. My health, my physical strength, my coordination, my blance and my ability to follow or to give directions while climbing or performing physical training might not be enought to safely practice indoor climbing;

5. Fatigue, shivers and drowsiness that can reduce reaction time and increase potential risk;

6. Scratches caused by equipment or the structures;

7. Presence, actions or falls of other participants;

I understand that this is not an extensive description and that other unknown risks could cause injury, sickness or death.

I agree to play an active role in risk management by having a preventive attitude towards myself and towards others around me.

HEALTH AND PHYSICAL CONDITION

I hereby state that I am in good physical condition and that I have no personal health problem preventing me from participating in the activities offered at Centre d'escalade Bloc Shop. I agree to disclose any physical or mental contidition that could have an impact on my safety or the safety of others.

RISK AGREEMENT

I accept all risk of physical injury, accidents or sickness, including sprains, tears, fractures, eye problems, cuts, scratches, contusions, dehydration, lack of oxygen, vertigo, head, neck or spinal trauma, lung problems, nervous breakdown, paralysis and-or death.

I TAKE FULL RESPONSIBILITY FOR CHOOSING MY SPOTTING PARTNER.

RULES AND REGULATION AGREEMENT

I hereby agree to having understood, and accept to respect and follow the Centre d'Escalade Bloc Shop rules and regulation. A copy is posted in the facility. I have read it and understand it. Centre d'Escalade Bloc Shop and its representatives reserve the right to refuse or withdraw access to its facility to anyone displaying a dangerous conduct regarding indoor climbing safety or any participant who refuses to abide by the Centre d'Escalade Bloc Shop rules and regulations. 

HELMET

I understand that wearing a helment can reduce the risk of head trauma, that I am personally responsible for my decision of wearing a helment or not. It is my responsibility to wear a helmet.

CHILDREN CLIMBERS AND VISITORS

I hereby state that the child for which I am signing is truly my own biological son, daughter, or that I am truly his or her legal guardian. I agree to follow the rules and regulation that I have read and understood when I am in presences of children at Bloc Shop as a climber and as a host.

PHOTOGRAPHY AND MARKETING

I hereby authorize Bloc Shop to use pictures and video material for publicity without receiving compensation.

FALLING AND SAFETY ORIENTATION

I understand that for everyone's safety, I mustparticipate in a safety orientationbefore my climbing activity.


I understand that I must respect my own body and abilities when chosing a climbing height. 


GENERAL AGREEMENT

I hereby state that I have read and understood the risk acknowledgement form presentend. OF MY OWN FREE WILL, I ACCEPT ALL THE RISKS AND DANGERS PREVIOUSLY MENTIONNED. And I accept to respect the rules and regulations of "Centre d'Escalade Bloc Shop".

Date: May 8, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

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 or Guardian's Email Address

Email*

Confirm Email*
Can we email to communicate events and amazing offers?
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Please complete the following with : "Yes, I understand"

... that in order to increase my safety, I must practice falling by increasing fall height progressively. *

...that for my safety, I must participate in a short orientation with a Bloc Shop staff before climbing. *
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 Information

I understand that the personal data collected in this form will be used for identification and customer follow up durning my Bloc Shop journey.

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE! and  Rock Gym Pro