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 incomplete 9elds below

Facility Waiver Details

ADULT/GUARDIAN DETAILS

First Name *

Senayit

Last Name *

Halefom

Email *

halefomsenayit@yahoo.co.uk

Mobile Number *

07596276069

Date of Birth *

21 Apr 2014

ADDRESS

Address *

101 New park Road

Town / City *

London

Postcode *

Sw24Bu

Country *

Uk

EMERGENCY CONTACT INFORMATION

First name *

Senayit

Last name *

Halrfom

Mobile *

07506276069

Emergency Medical Information

Non

Please include any emergency medical information our staff or

paramedics may need to be aware of in case of an accident.

QUESTIONS

Please carefully read the questions below and check the box to
answer 'Yes' to each question, leave the box clear to answer 'No'.

Please click HERE to review our Participant Statement &

Conditions of Use and HERE to view our Induction Video.

Do you agree to abide by the rules of the

centre? *

Do you understand that the matting does not

guarantee your safety? *

Have you read and understood the conditions

of use of the centre and agree to them? *

Do you understand that failure to exercise due

care could result in injury or even death? *

Did you watch the induction video and

understand the information provided within it?
*

Do you understand that you will be bouldering

without supervision? *

Do you understand that you are not allowed to

climb on the roof trusses and girders? *

Please let us know how you heard about us: *

Search engine (Google, Bing etc.)
Instagram
Facebook
Poster or Banner
Word of Mouth
LeaAet
Publication
Other

Include Minor(s)

MINOR DETAILS

Please complete this section for each minor you add.

The minor's legal parent or guardian must complete this section.

This can not be completed by another adult.

If you are 14-17 years of age and wish to climb unsupervised you
must complete this and then an additional assessment.

First Name *

Jay-Nathan

Last Name *

Tewdros

Date of Birth *

7 Dec 2014

PARENT / LEGAL-GUARDIAN QUESTIONS ABOUT

MINOR
Do you understand that your child
must be supervised at all times
whilst in the centre by a registered
unsupervised adult (over the age of
18)? *
Yes

Are you the legal guardian of the

aforementioned minor and as such
will you ensure that they honour their
obligations as laid out within this
document? *
Yes

DECLARATION OF CONSENT

I give consent to allow the named minor to use the

facilities at Substation under the supervision of a
registered unsupervised adult.

Parent / Legal-Guardian Name: *

Senayit

Parent / Legal-Guardian Signature: *

Clear
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.

 Add Minor Details

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