NEMBY Jr.

Indoor Rock Climbing Permission Form

DATE: Thursday, November 7th LOCATION: Peaks Indoor Rock Climbing, 630 Welland Ave., St. Catharines TIME: 6:30 PM to 8:30 PM COST: $15.00 CONTACT: Mark Durksen if you have any questions: 905-937-6900 or markdurksen@hotmail.com OTHER INFORMATION: Appropriate clothing for climbing is T-shirts, shorts or track pants and running shoes. Also, you will need to wear a helmet. Peaks recommends that you bring your own (a bike helmet will do). They offer rental helmets at no extra charge, but there may only be a limited number.
Name: _____________________________________________________ Phone #: _________________________________ Address: ___________________________________________ City: _________________________ Postal Code: ________ OHIP #: ____________________________________ Allergies: _________________________________________________ Medications being taken: ________________________________________________________________________________ Emergency Contact Person: _________________________________________ Phone #: ____________________________ Student Co-operation Agreement Were glad that youre coming indoor rock climbing with us and we hope that youll have a great time. To keep things enjoyable for everyone, there are a few simple guidelines to remember and live by: Parental Permission I give my permission for the above named student to go indoor rock climbing with NEMBY at Peaks Indoor Rock Climbing. I understand that all reasonable safety precautions will be taken at all times by NEMBY youth leaders during the event described above. I understand the possibility of unforeseen - Be respectful to the facility and follow all Peaks Indoor hazards and know the possibilities of risk. I agree not to hold Rock Climbing rules and guidelines. Scott St. MB Church, Fairview MB Church or Grantham MB - Do not be disruptive to other patrons. They are there to Church or their employees or volunteers liable for damages, enjoy the facilities. - Respect the students and adult leaders you are with. If an losses or emergency. I hereby authorize an adult leader as agent for me, to consent to any X-ray examination, medical, adult leader tells you to do something, obey them. dental or surgical diagnosis, treatment, and hospital care I have read the above Co-operation Agreement and, by advised and supervised by a physician, surgeon or dentist (as signing below, agree to abide by it. appropriate) licensed to practice under the law of Ontario where the services are rendered, either at a doctors office or Student Signature: in a hospital. I expect to be contacted as soon as possible in this event. _________________________________ Signature of Parent/Guardian: Date Signed: ___________________________ ___________________________ Date signed: __________________