DELHI ROCK - UNDER 18
This form must be signed by a legal guardian of the participant. Delhi Rock reserves the right to deny admission to anyone we determine unable to meet the physical, mental, or safety needs of participation without risk of harm to his or her self and others.
Date and time of planned activity *
DOES YOUR WARD HAVE ANY OF THE FOLLOWING CONDITIONS?
1. Chest pain, high blood pressure, heart problems *
2. Asthma, bronchitis, tuberculosis, sinusitis, other lung problems *
3. Fits, epilepsy, fainting attacks, migraine, head injury *
4. Nervous illness *
5. Diabetes *
6. Allergy to medicines / food / others e.g. chalk, foam *
7. Any present or past history of back or spinal injuries *
8. Any present joint dislocations or sprains *
9. Carrier status for any infectious disease *
10. Any disabilities or any other medical information to note
INDEMNITY, ACKNOWLEDGEMENT, WAIVER, & RELEASE FROM LIABILITY

This document is a legally binding agreement. By signing this agreement you are acknowledging that you have read, understood and accepted the terms and conditions stated in this agreement. You further acknowledge and agree that you are waiving your rights and your ward’s rights to bring any court action to recover compensation or obtain any other remedy for any injury to your ward or your property.
ACKNOWLEDGEMENT

I acknowledge that there are significant risks associated with the activities conducted by Delhi Rock and its affiliates. I further acknowledge the nature and extent of the risks inherent in these activities. I acknowledge that there are risks associated with the uses of the facilities or venues employed by Delhi Rock and its affiliates, and that other unknown and unanticipated risks may result in injury or illness.
RELEASE, ASSUMPTION OF RISK AND RESPONSIBILITY

In consideration of, and in recognition of the inherent risks of the activities my ward undertakes, I agree not to hold liable Delhi Rock and its partners, instructors, employees and affiliates, for any and all claims or demands, obligations and/or causes of action.
I FURTHER CERTIFY, ACKNOWLEDGE AND AGREE THAT

My ward is capable of participating and of use of equipment; I assume responsibility for and voluntarily assume the risks for any injury to my ward and related expenses involved with interactions with Delhi Rock; I assume responsibility for damage to my property and my ward’s property; and I assume the risks for any accidents or injuries to my ward caused by the negligence of their belayer, spotter or other co-participants.

I further acknowledge my ward’s obligation to follow the instructions provided to him or her by his or her instructors and associates of Delhi Rock; to agree to the marked, indicated and sanctioned use of the facilities or venues employed by Delhi Rock, and the equipment, installations and structures within. I permit Delhi Rock’s staff members to call emergency medical services in case my ward is incapacitated by injury or illness.
IN WITNESS WHEREOF

The information provided is true to the best of my knowledge and I did not withhold any vital information. I have signed this agreement on this day.
Name *
Ward's name (can be more than one) *
Address *
Signature (full name in capitals) *
Date *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Delhi Rock.