Climbing Agreement, Acknowledgment of Risk and Release


Please compete the form and sign the waiver.





This is the person participating in any activities. If the participant is a minor, the form must be signed by a parent or legal guardian.
Participant Name

First Name *

Last Name *
Date of birth of the participant, not the person signing the waiver.
Participant Date Of Birth *
Participant Gender *
Male    
Female    
Other     

Stout Students, Faculty & Staff are required to use their Stout email address.
Email Address *

Phone Number *

How did you hear about the Stout Adventures Climbing Wall? *
RETURNING USER    
Word of Mouth (Peer, Staff Member, Etc)    
Poster    
Social Media    
Brochure/Flyer    
Website/Internet    
Email    
Info Booth    
Other     


Electronic Signature Consent  *
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

SAVE INFORMATION FOR ADDITIONAL DOCUMENTS

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