U-21
CLIMBING COURSES WAIVER FORM (For Participants under the age of 21 yrs.)
1. This form must be signed by Parent/Guardian of the participant. 2. Climb Asia reserves the right to deny admission to anyone whom we determine unable to meet the physical, mental, or safety demands of our course.without risk of harm to his/her self or others.
Name of Course/Programme
Date of Course/Programme
Name of Participant
NRIC/Passport No.
Venue
Age
Gender
M Address
Home Contact No.
F
Postal Code
Mobile Contact No.
Person to notify in case of an emergency Name of Parent/Guardian
Home Contact No.
NRIC/Passport No.
Mobile Contact No.
Relationship
Office Contact No.
INDEMNITY I am aware that *my child's/my ward's participation in climbing activities involves a certain amount of risk. It is also intended only for those without significant medical problems (including recent infections or injuries) and those who have been exercising regularly. I shall not hold Climb Asia Climbing Centre Pte Ltd or their staff, instructors and agents responsible for any damage to or loss of property or any injury or loss of life which may be sustained by *my child/my ward during the course or arising from any cause in connection with the usage of the climbing facilities.
Parent/Guardian/Responsible Party’s Signature
Date
MEDICAL DECLARATION To assist us in knowing your medical history better, please fill in the questionnaire below and attach it together with any relevant documentation proof. Thank you! Do you have any conditions that may adversely affect your capacity to participate in this course? 1. Chest Pain, High Blood Pressure, Heart Problems e.g. Heart Murmur, Extra Heartbeat Or Other Heart Abnormality)
Yes / No
2. Asthma, Bronchitis, Tuberculosis, Sinusitis, Other Lung Problems
Yes / No
3. Fits, Epilepsy, Fainting Attacks, Migraine, Severe Head Injury
Yes / No
4. Nervous Illness
Yes / No
5. Diabetes
Yes / No
6. Allergy To Medicines / Food / Others e.g. Chalk, Foam.
Yes / No
7. Any Present / Past History Of Back Or Spinal Injuries
Yes / No
8. Any Present / Past History Of Dislocations / Sprains
Yes / No
9. A Carrier Status For Any Infectious Disease
Yes / No
10. Have You Any History Of Mental Or Psychological Illnesses Of Any Kind, Fear Of Confined Small Space, Crowds Or Panic Attacks
Yes / No
11. Do You Have Any Disabilities or any other Medical Information to note.
Yes / No
UNDERTAKING BY APPLICANT AND PARENT/GUARDIAN The information provided is true to the best of my knowledge and I did not withhold any vital information.
Participant’s Signature
Date
CLIMB ASIA CLIMBING CENTRE PTE. LTD. 60, Tessensohn Road c/o Civil Service Club. Singapore 217664. Tel: 6292 7701 Fax: 62922281
ADULT
CLIMBING COURSES WAIVER FORM
1. Climb Asia reserves the right to deny admission to anyone whom we determine unable to meet the physical, mental, or safety demands of our course.without risk of harm to his/her self or others.
Name of Course/Programme
Date of Course/Programme
Name of Participant
NRIC/Passport No.
Venue
Age
Gender
M Address
Home Contact No.
F
Postal Code
Mobile Contact No.
INDEMNITY ACKNOWLEDGEMENT, WAIVER, & RELEASE FROM LIABILITY AGREEMENT 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 TO BRING ANY COURT ACTION TO RECOVER COMPENSATION OR OBTAIN ANY OTHER REMEDY FOR ANY INJURY TO YOUR SELF OR YOUR PROPERTY. ACKNOWLEDGEMENT: I acknowledge that there are significant elements of risk associated with the sport of rock climbing & bouldering. I further acknowledge the nature and extent of the risks inherent in rock climbing and the use of the facilities. I acknowledge that there are possible risks associated with the use of the facility, and that other unknown and unanticipated risks may result in injury, illness, or death. RELEASE, ASSUMPTION OF RISK AND RESPONSIBILITY: In consideration of, and in recognition of the inherent risks of the activity associated with the use of the facility, I agree not to hold liable CLIMB ASIA CLIMBING CENTRE & its directors, shareholders, instructors and employees, for any and all claims or demands, obligations and/or causes of action of any nature whatsoever. . I further certify, acknowledge and agree that: I am physically and mentally capable of participating in the activity and/or use the equipment; I assume responsibility for and voluntarily assume the risks for any personal injury, death and related expenses involved with this activity; I assume responsibility for damage to my personal property; and I assume the risks for any accidents or injuries caused by the negligence of my belayer or spotter. IN WITNESS WHEREOF, I have signed this agreement on this day.
Signature
Date
MEDICAL DECLARATION To assist us in knowing your medical history better, please fill in the questionnaire below and attach it together with any relevant documentation proof. Thank you! Do you have any conditions that may adversely affect your capacity to participate in this course? 1. Chest Pain, High Blood Pressure, Heart Problems e.g. Heart Murmur, Extra Heartbeat Or Other Heart Abnormality)
Yes / No
2. Asthma, Bronchitis, Tuberculosis, Sinusitis, Other Lung Problems
Yes / No
3. Fits, Epilepsy, Fainting Attacks, Migraine, Severe Head Injury
Yes / No
4. Nervous Illness
Yes / No
5. Diabetes
Yes / No
6. Allergy To Medicines / Food / Others e.g. Chalk, Foam.
Yes / No
7. Any Present / Past History Of Back Or Spinal Injuries
Yes / No
8. Any Present / Past History Of Dislocations / Sprains
Yes / No
9. A Carrier Status For Any Infectious Disease
Yes / No
10. Have You Any History Of Mental Or Psychological Illnesses Of Any Kind, Fear Of Confined Small Space, Crowds Or Panic Attacks
Yes / No
11. Do You Have Any Disabilities or any other Medical Information to note.
Yes / No
UNDERTAKING BY APPLICANT The information provided is true to the best of my knowledge and I did not withhold any vital information.
Participant’s Signature
Date
CLIMB ASIA CLIMBING CENTRE PTE. LTD. 60, Tessensohn Road c/o Civil Service Club. Singapore 217664. Tel: 6292 7701 Fax: 62922281