2015 Rock Wall Participation and Release Agreements

Par cipants Full Name:

Par cipants Age:

Parent or Guardians Name:

Birth Date of Adult:

Address:

City:

State:

Zip:

Phone number:

Email:

Emergency Contact:

Phone Number:

YES
NO
YES
NO
YES
NO

I HEREBY GIVE PERMISSION for myself/my child to par cipate in indoor rock climbing ac vi es at CMRC. I am aware
that the sport of climbing, the use of a climbing wall and climbing equipment pose poten ally serious risks of injury. I
understand that I may be injured as a result of my negligence, or through no fault of myself or anyone else, because of
the nature of the ac vity in which I am going to be engaged.
I DO HEREBY FOREVER DISCHARGE, RELEASE, INDEMNIFYAND HOLD HARMLESS the County of Loudoun and the PRCS,
their ocers, servants and employees against any and all claims of property damage or injury to myself, my child or
others arising as a result of mine or my childs par cipa on in this ac vity.
I KNOWINGLY AND FREELY ACKNOWLEDGE AND ASSUME ALL RISKS, including but not limited to the risk of bodily injury
or property damage. I assume full responsibility for my par cipa on and use of the CMRC rock wall.

YES
I AGREE TO COMPLY with all the posted rules and regula ons for the Rock Wall at CMRC.

NO

Helmet waiver (op onal except for summer camps)

YES I, the undersigned, recognize the dangers inherent with climbing ac vi es and assume the hazard of this risk upon myself/my child. I realize no form of preplanning can remove all the danger to which I am exposing myself. I have been
NO oered a protec ve helmet, which could prevent brain damage in the case of an accident. Against the advice of CMRC,
PRCS, the County of Loudoun, and its insurers, I am refusing this safety precau on for myself/my child.
Par cipants Signature:

Date:

Parent/Guardians Signature:

Date:

For Parcipants under the Age of 18 and older than 6 years old
This is to cer fy that I, as parent/guardian with legal responsibility for this par cipant, hereby accept the
above assump on of risk and hereby release and agree to indemnify and hold harmless CMRC from any and
all liabili es incident to my minors involvement or par cipa on in any use of the CMRC rock wall. I have
discussed the inherent dangers of rock climbing with my child and fully understand the risks involved.

I have carefully read this parcipant agreement and fully understand its terms.
Parcipant/Parents Signature _____________________________________________ Date: ____/____/___

Mother Father Guardian