Class Enrollment Form

Notes: Complete and Check Form Options.

1. Above, check class of interest and provide the number of expected class participants.

2. Rock climbing classes, offered through the Bouldering Garden, include admission, safety equipment rental, and instruction.

3. Classes are for most ages but require maturity, an attention span, demonstrate safety, and the ability to acknowledge the risks of rock climbing.

4. Rock climbing can be a safe and enjoyable activity, if safety procedures are followed and respected.

5. A participant waiver and acknowledgement of risk must be signed by the participant, or adult parent, if the participant is less than 18 years of age.

6. Below, provide participant’s age, waist size, and shoe size for safety equipment requirements.

7. An additional waiver must be completed and turned in with class enrollment form. Fill out as many waivers required for class participants.

Participants Names (Printed) Adult / Parents Signatures

1^st Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

2^nd Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

HEALTH AND ACCIDENT INFORMATION:

Person to contact in case of emergency should parents be unavailable:

Phone: ( ) ___________________ Business: ( ) _____________________

IN CASE OF SURGICAL EMERGENCY, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. I understand that all medical bills incurred for treatment of illness or accident will be forwarded to me for payment.

Printed: _____________________________ Signature X ______________________________________________

(Parent’s or guardian)

Date: ________________ Student’s Full Name: _______________________________________________

Health and Accident Insurance Co. _____________________________________________________________

Health and Accident Insurance Co. Address ______________________________________________________

Phone _____________________________________

Group Policy # ______________________________ Ind. Policy # _______________________________

Policy under the name of: ___________________________________________________________________

www.theboulderinggarden.com Gym (573) 474-4997

Columbia Rock Climbing Gym

Waiver & Acknowledgment of Risk

Participation in Activities at the Bouldering Garden Involves Risk Attendees must be at least 18 years of age and (or a parent / guardian of participant) must read and sign a yearly waiver, sign a daily waiver, read the posted gym rules, and double check all safety equipment.

Initial X’s

2010 Membership Agreement & Acknowledgment of Risk Waiver

____ 1. By signing in below and or completing required contact information, you ("the participant") demonstrate your willingness to participate in the sport of indoor and outdoor rock climbing at, and or with, Metamorphic Forms, dba the Bouldering Garden, and acknowledge the inherent risks that come along with the sport of rock climbing, bouldering, mountain climbing, rappelling, and other related activities. These risks include but are not limited to Death and or dismemberment.

____ 2. By signing below, you are demonstrating that you understand and are aware that indoor rock climbing at, and or with, Metamorphic Forms, dba the Bouldering Garden, like many sports, is a potentially hazardous activity that can produce injuries, during normal activities, that include, but are not limited to, abrasions, cuts and bruises, broken bones, tendinitis, emotionally traumatic repercussions from a possible fall, acrophobia attacks, heart attacks, and possibly death. You are further acknowledging that you understand that there are also other remote risks that may be associated with climbing or attending an activity at, and or with, Metamorphic Forms, dba the Bouldering Garden, or its owner's, staff, volunteers, students, certified belayers, members, property owners, and contracted services.

____ 3. By signing below, you're representing, despite the fact that a complete accounting of the remote, but ever present risks of injury have been provided to you, that you're still interested and have a continued willingness or desire to pursue, and or allow the participant to pursue to activities at hand. You are at this time, acknowledging that all of your questions have been answered to complete satisfaction concerning risks involved and want to participate, and or as the parent and or guardian of potentially allowed participants to participate, despite this fully disclosed waiver and discussion of risks describe within, but not limited to, this document.

____ 4. By signing below, you profess that I have read and understand the rules concerning climbing at Metamorphic Forms, dba the Bouldering Garden.

____ 5. By signing below, you're stating that you are participating at your own risk and will not hold the Bouldering Garden, or its owner's, staff, volunteers, students, certified belayers, property owners, and contracted services liable for any situations that arise due to your negligence, misbehavior, any accidental faulty equipment, or misjudgment, on behalf of Metamorphic Forms, dba the Bouldering Garden, or its owner's, staff, volunteers, students, certified belayers, members, property owners, and or contracted services. Furthermore, you understand that, any and all, legal expenses shall be paid by you, the participant, or guardian of said participant. You are acknowledging your understanding and responsibility to pay, any and all, medical expenses which may occur during, or as a result, of participation.

____ 6. By signing below, you are further acknowledging and agree that Metamorphic Forms, dba the Bouldering Garden and property owners reserves the right to deny or relinquish participant privileges, and or entrance to the facility, for any reason it, or its owner's, staff, volunteers, and contracted services see fit. You now understand that a list of rules, on the gym wall, available on paper, and available verbally, spell out general guidelines designed with safety in mind. You further understand that horseplay, misbehavior, breaking of rules, foul language, and no-compliance, or non-compliant, with any staff recommendations could result in the termination of your facility privileges. You also understand that smoking, foul language, unapproved fighting, unapproved weapons, and alcoholic beverages are prohibited on the premises.

____ 7. If you have participated in a belay certification class and or have a complete understanding and working knowledge of the belay certification requirements at Metamorphic Forms, dba the Bouldering Garden, or wish to participate as a belayer during activities, then by signing below you are acknowledging that you understand fully your responsibility to help keep those around you safe and having fun, acknowledge the potential risks of injury, and risk of legal repercussions.

____ 8. BY PRINTING NAME BELOW, YOU ARE AKNOWLEDGING that you have read and fully understand the information contained herein, therefore agree to the terms, understand the potential risk of serious injury, or death, as a result of my participation, or the participation of those for which I am guardian, am at least 18 years of age, have medical insurance coverage, assume liability for actions, and waiver my right to sue Metamorphic Forms, the Bouldering Garden, or its owner's, staff, volunteers, students, certified belayers, or property owners.

____ 9. My signature below, acknowledges, that I, (Print Name) _______________________________________,

am at least eighteen (18 ) years of age, am my own guardian and or guardian of said participants listed below, on the date of, (Date) ____________ , have fully had the opportunity to read, have read and fully understand the information contained herein, therefore agree to the terms, understand the potential risk of serious injury, or death, as a result of my participation, or the participation of those for which I am guardian, am at least 18 years of age, have medical insurance coverage, assume liability for actions, and waiver my right to sue Metamorphic Forms, the Bouldering Garden, Columbia Climbing Gym or its owner's, staff, volunteers, students, certified belayers, Members, or property owners. (Parents & Guardians Signatures are required if participant is under the age 18 and or cared for by a guardian)

Participants Names (Printed) Adult or Parents Signatures

1^st Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

2^nd Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

3^rd Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

4^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

5^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

6^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

7^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

8^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

9^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

10^th Participant's: ______________________________ Age: _____ Waist Size: _____ Shoe Size: _____ X _________________________________

Contact Name (adult): ______________________________________ Age: ______ Signature X ____________________________________

Email: _______________________________________________________ Phone: ______________________________________ Cell: ______________

www.theboulderinggarden.com 5400 Saint Charles Road Ste C Columbia MO 65201 (573) 474-4997