Participant Consent and Medical History
I UNDERSTAND THAT I AM BEING ASKED TO READ THE FOLLOWING DOCUMENT CAREFULLY. I UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT UW-STOUT SAFETY & RISK MANAGEMENT SERVICES, AT 715-232-2188.
LIABILITY WAIVER:
ASSUMPTION OF RISKS:
I understand that not all risks can be foreseen and there are some risks which are unpredictable. I understand that certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I am aware of the risks of participation, which include, but are not limited to, the possibility of physical injury, fatigue, bruises, contusions, broken bones, concussion, paralysis, and even death. I understand that the university has advised me to seek the advice of my physician before participating in the Stout Adventures programming. I understand that I have been advised to have health and accident insurance in effect and that no such coverage is provided for me by the University or the State of Wisconsin. I know, understand, and appreciate the risks that are inherent in the above-listed programs and activities. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
HOLD HARMLESS, INDEMNITY AND RELEASE:
In consideration of my participation in these activities, I, for myself, spouse, heirs, personal representatives, estate or assigns, agree to defend, hold harmless, indemnify and release the Board of Regents of the University of Wisconsin System, the University of Wisconsin-Stout, and their officers, employees, agents, volunteers, and all others who are involved, from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from my participation in the above-listed program. This release includes claims based on the negligence of the Board of Regents of the University of Wisconsin System, the University of Wisconsin-Stout, and their officers, employees, agents, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence. I understand that by agreeing to this clause I am releasing claims and giving up substantial rights, including my right to sue.
CONSENT FOR EMERGENCY TREATMENT:
I authorize the University of Wisconsin-Stout and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
PHOTO/MEDIA RELEASE:
I grant University Recreation and UW-Stout Adventures the right to use, reproduce, assign and/or distribute photographs, films, and videotapes of myself for use in materials they may create.
By signing this, I acknowledge that I understand and agree to the above statements.
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Please select who will be participating....
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Signature of Parent or Guardian (If participant is under 18)
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Additional instructions for the previous question. Please note the following:
12yrs and under: participants must have constant adult supervision at the climbing wall.
12-15yrs: participants must have an adult within/around the facility.
Parent or Guardian's First and Last Name.
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Parent or Guardian's phone number.
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Participant's First or Chosen Name
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Participant's Last Name
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Participant's Preferred Pronouns
Emergency Contact (Name and Phone Number)
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Important Information about the next question. Please select one. Pay careful attention to the start and end times of your membership option.
I am purchasing this membership...
Important Information about the next question. If you select "Yes" to ANY one (1) or more of the following medical history questions, is it highly recommended that you consult your physician before you start to become more physically active. Any activity or exercise resulting in pain, faintness, dizziness, or shortness of breath should be stopped immediately.
Do you feel pain in your chest when you do physical activity?
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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Is your doctor currently prescribing drugs for your blood pressure or heart condition?
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Are you currently taking any medications or receiving other treatments related to diabetes?
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Do you know of any other reasons why you should not do physical activity?
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Important Information about the next question. Climbing Wall Rules and Policies
FACILITY ACCESS
• A valid, UW-Stout ID should be presented to gain access to the facility. Your membership will be activated on your Stout ID within 24-
72 hours after you purchased your climbing wall membership AND complete this waiver.
• You will NOT be permitted to use the facility without your ID. NO ID, NO ENTRY!
• Membership cards will be issued to those with UW-Stout Family Memberships or Community Memberships. If this card is lost or stolen
within the issued year a $5 fee is required to replace the card.
GENERAL
• No bags or backpacks in the climbing wall area. Please use the cubbies.
• All participants under the age of 16 MUST be accompanied by a parent or guardian and children 12 and under must have
constant adult supervision unless authorized by the Stout Adventures Coordinator.
• Appropriate language and conversation is expected.
• Climbing with personal music devices, headphones, earbuds, etc. is prohibited.
• Food and beverages are not permitted in the climbing wall area except for water.
• The wearing of jewelry during climbing is strongly discouraged.
• Climbers and belayers must always wear shoes.
• Shirts are required.
• ONLY liquid chalk or chalk shots (no loose chalk).
• Do not swing on rings or ropes.
• It is prohibited to climb on any building walls. Climbing is only allowed on the climbing wall.
• Do not use metal bolts for hand or foot holds.
• Climbers may use their own harness and shoes, but it must be approved by the climbing wall staff prior to use.
• When using the Auto-Belay do not jump away from the wall, fall as straight down as possible.
• For bouldering, the climber’s hands shall not exceed the “Do not boulder” holds on the wall.
• Spotters and crash pads are strongly encouraged.
• While bouldering you may not boulder under other climbers.
• A FIGURE 8 follow through knot will be used to secure the climber’s harness to the rope. Yosemite finishes and other knots besides
the figure 8 follow through are prohibited.
• All belayers must complete a climbing wall belay class or pass a skills check before belaying.
• Belayers must use proper belay technique (Pull-Lock-Under-Slide).
• Belayers must lower with proper technique. Fast descents are prohibited.
• ALWAYS check and double check the climber’s knot, harness and the belay system before EACH climb.
• Proper climbing/belaying commands should be used.
• Lead climbers and their belayers must meet the pre-requisites and pass the lead climbing clinic or pass a skills check.
• The adjustment or rearrangement of holds is not permitted. The routes will be changed periodically by the climbing wall staff.
• Only instruction provided by climbing wall staff is permitted.
• Climbing wall staff are authorized to give a warning for not complying with the climbing wall rules. If there is another offence, climbing privileges will be suspended until you have met with the SA Coordinator.
• Our memberships are NON-REFUNDABLE, NON-TRANSFERABLE, and may NOT BE FROZEN!
Violation of any rules or policies can result in suspension of climbing privileges. This is left to the discretion of Stout Adventures staff. Please follow staff member instruction. Staff, rules and polices exist for your safety!
By signing below I certify that I have read and understand all the policies and procedures written above and any addendums. I agree to follow all statements and understand I may be asked to leave the facility, be suspended or lose my membership if I do not abide by the rules. My signature also certifies that all previous answers are truthful and if anything should change I will let UW-Stout Adventures know of these changes. If I have any questions or am unclear on any of this material, I will ask the Stout Adventures Staff.
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