NBRH Joining Application & Waiver of Liability

First Name *

Last Name *

Date Of Birth (DD/MM/YYYY): *

Phone Number *

Email Address *

Street Name & Number *

Address Line 2

Suburb / Town *

State / Territory *

Postcode *

Country *

Do you wish to add a minor/dependent? *

YesNo

Minor/Dependent #1

First Name *

Last Name *

Dependent 1 - Date Of Birth (DD/MM/YYYY): *

Same Address & Phone as above? *

YesNo

Add alternative address & phone here: *

Do you wish to add a 2nd dependent? *

YesNo

Minor/Dependent #2

First Name Dependent #2 *

Last Name of Dependent #2 *

Dependent 2 - Date Of Birth (DD/MM/YYYY): *

Same Address and Phone as above? *

YesNo

Add alternative address & phone here: *

Do you wish to add a 3rd dependent? *

YesNo

Minor/Dependent #3

First Name Dependent #3 *

Last Name Dependent #3 *

Dependent 3 - Date Of Birth (DD/MM/YYYY): *

Same Address and Phone as above? *

YesNo

Add alternative Address & Phone here: *

Do you wish to add a 4th dependent? *

YesNo

Minor/Dependent #4

First Name Dependent #4 *

Last Name Dependent #4 *

Dependent 4 - Date Of Birth (DD/MM/YYYY): *

Same Address and Phone as above? *

YesNo

Add alternative Address & Phone here: *

Do you wish to add a 5th Dependent? *

YesNo

Minor/Dependent #5

First Name Dependent #5 *

Last Name Dependent #5 *

Dependent 5 - Date Of Birth (DD/MM/YYYY): *

Same Address and Phone as above? *

YesNo

Add alternative Address & Phone here: *

RELEASE - PLEASE READ CAREFULLY

You are advised that climbing is a Dangerous Recreational Activity with Obvious Risks as defined by the Civil Liability Amendment (Personal Responsibility) Act. YOU ARE PARTICIPATING AT YOUR OWN RISK.

I, the undersigned, and on behalf of all those named on this form, have read this release and the rules and regulations for the use of the premises and facilities of Northern Beaches Rockhouse Pty Ltd (“NBRH”). In consideration of being permitted to use the facilities:

I understand that indoor climbing involves risks that may cause various injuries and that such injuries may result in death or serious disability. I understand that indoor climbing is physically demanding, and in susceptible people may cause panic, hyperventilation or heart attack. I understand the risks of indoor climbing, wish to participate, and do so entirely at my own risk of injury or bodily harm to myself;

I Agree *

I am not under the influence of alcohol, drugs or any illicit substances. I understand that I am not permitted, now or ever, to use this facility while under the influence of alcohol, drugs or any other illicit substances;

I Agree *

I acknowledge that wearing any jewelry and or loose articles (including but not limited to ties, scarves etc.) of clothing is a potential risk while using this facility, and could lead to serious injury and accept this form as formal advice from NBRH to remove such items while on premise;

I Agree *

I understand that in order to climb or belay in the Lead Area in this facility, I must present myself to the staff and pass the standard NBRH Lead Assessment qualification prior to climbing or belaying in the Lead Area;

I Agree *

I hereby release Northern Beaches Rockhouse, the owner of the premises and all employees, staff and assistants of Northern Beaches Rockhouse, or any other persons involved in my participation in indoor climbing at Northern Beaches Rockhouse from any suit, demand, action or claim for compensation, whether for personal injury or damage to property arising from my participation;

I Agree *

I am aware that this waiver is ongoing, and will apply to all future occasions I participate in indoor climbing at Northern Beaches Rockhouse. I furthermore acknowledge that this document is contractual and may be relied upon in any proceedings by me, my heirs, executors and assigns;

I Agree *

I am aged 18 years or over and am legally competent to sign this agreement OR My parent or legal guardian has signed this form to consent to my participation.

I Agree *

PLEASE INITIAL - All parties named on this waiver agree with and understand the above release and all rules & regulations *

Electronic Signature Consent - By checking this box, you are consenting to the use of your electronic signature in lieu of an original signature. You have the right to request a paper copy to sign. By checking here, you are waiving that right. You may request a paper copy of any electronic record at any time after consent. By checking this box and signing electronically you agree that your electronic signature is valid on this document and any other document you sign until you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. *

TYPE FULL NAME - Applicant Signature (or Parent/Guardian if Applicant is under 18 years of age) *