Please Print in a Legible Handwriting

Name__________________________________________________

Address________________________________________________

              (Street)                              (City)                           (State) (Zip)

Phone No. (_____)______________ Date of Birth_______________

Email Address___________________________________________

ACKNOWLEDGEMENT OR RISK AND RELEASE FROM LIABILITY

There are elements of risk in climbing and using a zip line, which can result in accidents causing personal injury, death or damage to personal property. Known risks include but are not limited to: slips, trips or falls while observing or participating, loose or damaged climbing holds, equipment failure, mistakes by me or my spotter/belayer or by other persons in Alexandria Climbing Experience, or injuries from physical activity, such as strains and sprains. Also I understand that no one is

infallible, the staff at Alexandria Climbing Experience may be unaware of a participants abilities or limitations and may give inadequate warnings and or instructions. I am aware of these and numerous other unidentified risks associated with this activity.  I expressly agree and promise to accept and assume all of the risks existing in this activity.  My participation in this activity is

purely voluntary, and I elect to participate in spite of the risks

I confirm that I am physically and mentally capable of participating in the activity. I assume full responsibility for any personal or bodily injury, death, or damage to personal property as a result of any accident that may occur to me while at Alexandria Climbing Experience.

RELEASE AND PROMISE NOT TO SUE

I hereby agree to RELEASE FROM LIABILITY, and PROMISE NOT TO SUE Alexandria Climbing Experience, its owners, operator, manager, employee, volunteer or agent of Alexandria Climbing Experience, or any other person present at Alexandria Climbing Experience for injuries sustained by me while at the Alexandria Climbing Experience.

By signing I acknowledge that I have read and understood this document and agree to be bound by its terms.

________________________________________              ­­­_________________________

Signature of Participant                                                              Date

PARENT’S OR GUARDIAN’S RELEASE

(Must be completed for participants under the age of 18)

I am the parent or guardian of the minor listed above. I have read and understand the above release and agree that its terms shall bind me as well as any minor child and our heirs, legal representatives and assignees.

Printed Name of Parent/Guardian:

________________________________________

________________________________________              _________________________

Signature of Parent/Guardian                                                      Date