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Indoor Climbing Wall
Assumption of Risk and Release of Liability Form

This is a legal Document and must be read and signed by each participant prior to any activity on the climbing wall. The Recreational Activities Program and Cedarville University wants to insure that our participants have a rewarding experience on the wall. We do not want to reduce participants enthusiasm for the experience, but we do want them to know in advance what to expect and to be informed of the potential risks involved.

Assumption of Risk

I understand that there are inherent risks that cannot be eliminated from the sport of rock climbing and climbing on the indoor climbing wall. I have full knowledge of the nature and extent of these risks including but not limited to:

  1. Injuries resulting from falling and crashing into the climbing wall, floor, crash pads, or other objects.
  2. Injuries resulting from rope abrasion, entanglement, and other injuries that may result from activities or other persons, including but not limited to climbing, rappelling, belaying, lowering on a rope, rescue or emergency activities, as well as injuries, abrasions, and cuts resulting from contact with equipment and components of the indoor climbing wall facility.
  3. Failure of the ropes, harnesses, wall hardware, anchor points, or any other part of the indoor climbing wall structure and related equipment.
  4. Injuries from falling participants or equipment.
  5. Injuries resulting from the negligence of other climbers, belayers, spotters, spectators or users of the indoor climbing wall facility.
  6. Injuries resulting from personal physical and mental limits including but not limited to fatigue, chill, heat, and dizziness, which may diminish reaction time and increase risks of accident, personal strength, coordination, sense of balance, and the ability to follow or give directions while climbing, belaying, lifting, spotting, or being a spectator.
  7. Injuries or property damage resulting from hair or loose clothing getting caught in equipment.
  8. Injuries from improper use of equipment or the failure to properly tie into the system.
  9. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of my voluntary participation at the indoor climbing wall.

Release of Liability

I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility forbodily injury, death, loss of personal property and any expenses which may be incurred by me or any minor children in my care resulting from those inherent risks and dangers previously identified, those inherent risks and dangers not specifically identified, and any negligence on my part associated with my participation in this activity. I therefore release Cedarville University, its full time employees, student employees, volunteers, agents or representatives from any and all liability, claims, costs, expenses, injuries or losses including those resulting from acts of negligence by those stated above that I may sustain as a result in my participation in any activities at the CU indoor climbing wall. I also certify that I have adequate health, disability and life insurance for myself and my family and do not presume that the University has secured insurance for my benefit.

I have carefully read this Assumption of Risk and Release of Liability Form and fully understand its contents. By signing below I am accepting this contractual agreement.

I Agree

August 29, 2015

First Climber Name

First Name*

Last Name*

Phone*
First Climber Date of Birth*
First Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
First Climber Signature*
Second Climber Name

First Name*

Last Name*
Second Climber Date of Birth*
Second Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Third Climber Name

First Name*

Last Name*
Third Climber Date of Birth*
Third Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Fourth Climber Name

First Name*

Last Name*
Fourth Climber Date of Birth*
Fourth Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Fifth Climber Name

First Name*

Last Name*
Fifth Climber Date of Birth*
Fifth Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Sixth Climber Name

First Name*

Last Name*
Sixth Climber Date of Birth*
Sixth Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Seventh Climber Name

First Name*

Last Name*
Seventh Climber Date of Birth*
Seventh Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Eighth Climber Name

First Name*

Last Name*
Eighth Climber Date of Birth*
Eighth Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Ninth Climber Name

First Name*

Last Name*
Ninth Climber Date of Birth*
Ninth Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Tenth Climber Name

First Name*

Last Name*
Tenth Climber Date of Birth*
Tenth Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
11 Climber Name

First Name*

Last Name*
11 Climber Date of Birth*
11 Climber Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
I am the parent or legal guardian of the participant who has signed above. I have read and I understand the provisions of this document, I consent to the participant taking part in the activities described above, and I fully enter into and agree to the above Assumption of Risk, Release and Agreement for Participation in Fitness, Recreational, or Athletic Activities
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please Choose:*

Group:

CU 7 Digit ID#:

Belay Certification Date: Rec Center Staff will fill in this information

Lead Climbing Certification Date: Rec Center Staff will fill in this information
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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