Stalactites elite climbing club registration form - Taupo District Council

THE EDGE ROCKWALL
Stalactites Elite Climbing Club
Registration form
Monday’s 3:30-5:30, Thursday’s 5-7pm
Childs Name: Age: D.O.B:
Medical History/Cultural needs/Behaviour Problems – Please note even the smallest things:
Membership Number:
Term: _____
Start: _____
End: ______
(All information disclosed will remain confidential and kept only to serve purpose of child’s safety)
HEALTH: In case of emergency I give permission for my child to be given First Aid treatment by the programme staff or to be taken in an
ambulance if necessary – parents will be notified immediately Yes / No
Parents/Caregivers Details
Email contact:_____________________________________
Mother/Guardians Name: Father/Guardians Name: _
HOME Phone:
_ Address: _____________________________________________________
MOBILE Phone Mum: MOBILE Phone Dad: _
WORK Phone Mum: WORK Phone Dad: _
Emergency Name and Number (used if parents cannot be contacted):
_
I give permission for the above named child to participate in climbing activities at The Edge Rock Wall at the Taupo Events Centre on
the days indicated below, for term ________ year_____
MONDAY TUESDAY WEDNESDAY THURSDAY
FRIDAY SATURDAY SUNDAY
NOTE: If your child attempts to climb on a day not indicated above, they will
be refused entry to the wall!
I/We acknowledge that there is a risk involved in rock climbing and I have read the conditions noted on the reverse page and also
have read the Rules and Policies. I/We further acknowledge that these are the conditions upon which TAUPO EVENTS CENTRE
(TAUPO DISTRICT COUNCIL) have agreed to allow my child to participate in the activity of Rock Climbing.
I/We acknowledge that my child is participating at his/her own risk.
I/We further acknowledge that respect for the instructors/staff/other location instructors and staff/coachers/parents/ the public and others
participating is required. Children may be asked to leave any activity if this is not observed and parents will be informed.
I/We allow my child to be belayed by other children or parents participating in the Chalky midgets club.
I have read the full terms and conditions and agree to them:
Signed: Name: Date: __
(parent/guardian)
You are required to fill in a new form for each term
Equipment is not supplied outside of club times. Members must report to reception to swipe membership cards
upon entry before climbing. Minimum age for child to climb out of session times without parental or suitable
supervision is 13 years old.

Taupo Events Centre Edge Indoor Rockwall
Terms and conditions and disclaimer.
1. Risks: I am aware of, and understand, the inherent and unavoidable risks associated with rock wall climbing, abseiling or belaying
and that there is the possibility of bodily injury or death to myself or others and that there is also possibility of loss or damage to property
belonging to myself or others.
2. Abidance I agree to abide by any and all instructions given to me by Taupo Events Centre Staff, or Other Facility Staff either in
writing, by notice, or verbally by staff, or their authorised delegates.
3. Minimum Equipment Use: I agree to always wear and properly use an approved safety harness and friction device designed for rock
climbing and abseiling either climbing or belaying, when undertaking any rock climbing activity at Taupo Events Centre or when visiting other
locations. I also agree to use any other safety equipment required for the activity supplied by either TEC or the location / facility visited.
4. Belayer: I agree to always have a person properly belay me when attempting any climbing activity. Furthermore I accept that it is my
sole responsibility to ensure the competency of the Belayer and agree that Taupo District Council accepts no liability of any kind for any death,
injury, loss or damage should incorrect belay techniques contribute in any way to any accident or incident.
5. Acceptance of Own Responsibility: That fully understanding and being aware of the risks referred to in paragraph 1, I have
decided freely and voluntarily to accept all responsibility and liability for any death, injury, loss or damage whatever arising out of any use of the
Indoor Rock Climbing Wall at Taupo Events Centre, or whilst visiting any other facility/location. The Taupo District Council accepts no liability of
any kind for any death, injury, loss or damage however occasioned whether caused or contributed to by the negligence of the Taupo Events
Centre or otherwise and I forever waive release and discharge Taupo District Council from any and all liability for any death, injury, loss or
damage whatsoever arising from my use of the Indoor rock climbing wall at Taupo Events Centre, regardless of how such death, injury, loss or
damage is occasioned and including but not limited to circumstances where the death, injury, loss or damage is caused or contributed to by the
negligence of Taupo Events Centre, Taupo Events Centre staff or their authorised delegates.
I further agree to indemnify and otherwise hold harmless Taupo Events Centre and Taupo District Council from any and all loss, damage cause
of action, claims, costs and other liabilities whatsoever arising out of use of the Indoor rock climbing wall at Taupo Events Centre even if such
claims arise from the negligence of Taupo Events Centre, Taupo Events Centre staff or their authorised delegates, whether such claims can be
brought by me or on my behalf or brought by any other person.
6. Declaration as to Age and Physical Fitness/Medical History I declare that I am 18 years of age or older and physically fit and
have no condition or injury that could affect my ability to properly undertake climbing, abseiling, lead climbing those using the indoor rock
climbing wall at Taupo Events Centre. Nor do I have any condition or injury that could be aggravated or further deteriorate or worsen if I
undertake climbing, abseiling, lead climbing or belaying. I have informed Taupo Events Centre staff of any medical or other relevant information
concerning my child on this form.
7. (ONLY applicable if the climbers is under 18 years of age)
Guardian Responsibility: I am the legal guardian of a minor (a person under the age of eighteen (18) years who intends to participate in
activities on or in the vicinity of the indoor rock climbing wall at Taupo Events Centre, or at any other location/facility away from the TEC.
I agree that this Disclaimer and all its terms shall apply and bind the minor, his/her guardians, representatives, executors, administrators,
successors and assigns.
I warrant that I have the authority of any other guardian of the minor to sign this Disclaimer upon their behalf, and by doing so pass the
responsibility of the child over to the Staff from TEC for the duration of the trip.
8. Privacy Act
I give permission for my child to be photographed for newspapers, notice board advertisements and posters or for any other advertising material
for the Taupo District Council.
9. Acknowledgment of Disclaimer: I have read and understood the conditions of this Disclaimer and acknowledge that the
consideration referred to above is accepted by me as adequate and sufficient consideration for the terms imposed by this Disclaimer and I also
acknowledge that Taupo Events Centre have brought to my attention the matters referred to in paragraphs 5 and 6 prior to my signature of this
Disclaimer.
10. No Refund: I understand that should I decline to proceed with, continue with or reduce my intended use of the indoor rock climbing
wall at Taupo Events Centre, or at any other location for any reason I will not be entitled to any refund of any fees paid, whether for equipment
hire or for use of the indoor rock climbing wall, or other location/facility or activity.
I have read and understood the terms and conditions and am the parent/legal guardian of the participant.
Signed:
Name:
Date: