Informed Consent for Rockwall Climbing Participation

Name: _____________________________________________ Age: ____________ Today’s Date: ____________________________

Address: ________________________________________ City: ___________________ State: ______ Phone: __________________

I desire to engage voluntarily in LifeLines Health and Vertical Plains Rockwall in order to improve my overall health.

I know that I am required to fill out a Health Questionnaire before beginning to exercise. The information obtained from the questionnaire will be used to:
   ¨        Indicate any cardiac risk or other reason why I should not exercise.
    ¨        Determine the need for a physician’s evaluation and/or written approval before entering the exercise program.

I further understand that the reaction of the body to activity cannot always be predicted with complete accuracy. The changes that may occur and are associated with physical activity include, but are not limited to these signs and symptoms: delayed onset muscle soreness (DOMS), abnormal blood pressure or heart rate responses, breathlessness, chest discomfort, muscular or skeletal injury and in very rare instances, heart attack and death. I realize my responsibility in recognizing these potential hazards, monitoring myself before, during and after exercise, and seeking help in the event of injury, if possible. I will attend the orientation session and talk to the instructors to learn how to minimize these potential hazards and what I should do in an emergency. I understand that I can take steps to minimize my risk during exercise by following the steps noted below:

¨        I will not withhold any information pertinent to my health or condition to the instructor in charge of the program,
        and will immediately update my health and lifestyle questionnaire if changes in medication or status occur.
¨        I will report any unusual symptoms or problems that I experience before, during or after exercise.
¨        I will follow the amount and types of activities recommended during the orientation session.
¨        I will not exercise when not feeling well or for 2 hours after eating, smoking a cigarette, after drinking alcohol, or
        taking over the counter medications or street drugs.
¨        I will warm up before and cool down after exercises, and will not take an extremely hot shower after exercise.
¨        I will not undertake isometric, straining, or any other exercise I know by experience or my physician’s or therapist’s
        recommendation, to be painful or detrimental to me.
¨        I realize that exercise is performed at my own risk, even though I may be following guidelines or recommendations
        established during this program.
¨        There are risks and dangers associated with participation in rockwall climbing activities including but not limited to those
        of bodily  injury, partial and/or total disability, paralysis and death;
¨        There may be other risks not known to us or not reasonably foreseeable at this time;
¨        The social and economic losses and/or damages which could result from these risks and dangers described above
           could be severe.
¨        It is the participant’s personal responsibility to follow all belay instruction, including safety guidelines and protocol
        given by your instructor or any other instructor and/or management of Vertical Plains Climbing Center;

The information obtained from this exercise program will be treated as privileged and confidential and will not be released to any person without my written consent. Information regarding my health and program may be shared with instructors involved in my instruction or physical training. The information obtained may also be used for statistical or scientific purposes, with my right to privacy retained.

I, the undersigned, waive and release LifeLines Health, its employees, officers or directors, against any and all claims in any way connected with my participation in this program. This agreement is binding on my heirs and executors.

I acknowledge that I have read or heard this document in its entirety and that I fully understand it. Any questions which may have occurred to me have been asked by me and have been answered to my satisfaction. In consideration of the above factors, the undersigned participant acknowledges the risks in connection with these activities, assumes such risks and agrees to accept the responsibility for any injuries sustained by him/her in the course of his/her use of the following general areas:
             1.        The use of exercise equipment.
                2.        Possible injuries or medical disorders arising out of exercising at LifeLines Health.
                3.        Participation in exercise sessions that take place.
            4.        Accidents or injuries which occur within the building, such as the locker room, dressing room or shower.

I further understand that if at any time it is deemed by Vertical Plains Staff or management that I have not followed proper instruction and/or safety guidelines I may be asked to retake the belay safety certification course. This will include an additional belay certification course and/or I may be asked to leave the premises for an unspecified amount of time.  

___________________________     ____/____/____                              ___________________________     ____/____/____
Signature                                                  Date                                                        Staff Signature                                           Date

___________________________        ___________________________
Name (please print)                                   Phone Number