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Youth Climbing League Questionnaire

This information collected in this form is confidential. Only staff will have access to the information. 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Participant Information

Age *

Grade in School *
Has the child been enrolled in Youth Climbing League in the past?*
No
Yes
Emergency Contacts

Emergency Contact #1: NAME *

Emergency Contact #1: PHONE *

Emergency Contact #1: RELATIONSHIP *

Emergency Contact #2: NAME *

Emergency Contact #2: PHONE *

Emergency Contact #2: RELATIONSHIP *
Medical Information

Allergies (including allergies to medicines, foods, insect bites/stings) Include allergy, reaction if exposed and required medication (if any). If none, indicate N/A. *

Current Medications (including over-the counter & prescription medication, inhalers, etc.) Include name, what it is taken for, dosage, date started and current side effects. If none, indicate N/A. *

Does the child have pre-existing injuries (ankles, knees, back) or recent surgery that may be aggravated by the climbing wall? If so, please explain. *
Do you foresee any problem the child may have participating in the climbing wall due physical inactivity?*
No
Yes

Does the climber have any other physical limitations or medical concerns that the coaches should be aware of? *

Is there anything else we should know about the child (phobias, special sensitivities, physical limitations etc.)? *

Climbing is a physically and emotionally demanding sport. If there is any question concerning a climber's ability to participate at any time during the semester, or if your child sustains an injury or becomes ill and requires medication while they are a member of the Youth Climbing League, it is the parents' responsibility to notify the child's doctor and obtain approval for further participation in team activities. Moreover, parents must notify a coach that such approval has been obtained in writing. 

Other Information

Do you have anything else to add? Is there anything else the coaches should be aware of?

Who is authorized to pick up the child from Youth Climbing League? *
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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