Participant Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone

(###)

###

####

Secondary Phone

(###)

###

####

Email Address

Age

Date of Birth

YYYY

Program Information

Ice Climbing Program Selected

Date of Program

YYYY

Ice Climbing Location

Number in Group

Outing Goals

Relevant Climbing Experience

Ice Climbing Equipment Rental

Equipment

None (please verify with TCRI)

Harness (Edelweiss Challenge)

Helmet (Black Diamond Half Dome)

Carabiner and Belay Device (Omega Pacific Jake Screw-Lock Carabiner and Wild Country VC Pro II Belay Device)

Mountaineering/Ice Climbing Boots; Standard (Koflach Degre/Arctis Expe or Scarpa Inverno)

Crampons; Standard (Black Diamond Cyborg)

Boot Size (Please indicate Male or Female)

Release of Liability, Image Use, Waiver of Claims
Express Assumption of Risks and Indemnity Agreement
Please read and be certain you understand the significance of this document before signing.

Rock and ice climbing are inherently dangerous activities. such risks cannot be eliminated without jeopardizing the essential qualities of the activities.
I do hereby affirm and acknowledge that i have been fully informed of the inherent hazards and risks associated with Rock climbing and ice climbing activities, transportation of equipment related to the activities and traveling to and from the activity site of which i am about to engage.
Inherent hazards and risks include but are not limited to:
- Injury from the activity and the equipment utilized in rock and ice climbing.
- Injuries resulting from walking on uneven terrain, slips, trips, falls sustained, my own physical condition and/or the physical demands associated with hiking, rock and ice climbing.
- Possible equipment failure and/or malfunction of my own or other's equipment.
- Personal negligence, inadequate training and or negligence of others including Jason Cook and Margaret Tu. This includes, but is not limited to, operator failure.
Examples of possible injuries include, but are not limited to: sprains, strains, contusions, lacerations, broken bones, amputations, internal injuries, paralysis, head trauma, traumatic brain injury and death.
Injuries may occur from hypothermia, hyperthermia, hypoglycemia and dehydration. Cold injuries (hypothermia) include, but are not limited to frost nip, frostbite, gangrene, cardiac arrhythmias and death. Heat injuries include, but are not limited to sunburn, sunstroke, dehydration, seizures and death. Low Blood sugar (hypoglycemia) can cause headaches, visual changes, seizures and death. Fluid depletion (dehydration can cause electrolyte imbalance, fainting seizures and death.
- Injuries resulting from being struck by rockfall, icefall, or other objects dislodged or thrown from above.
- Exposure to outdoor elements, including but not limited to avalanche, rockfall, icefall, inclement weather, thunder and lightening, severe and/or varied wind, temperature and other weather conditions.
- Discharge of weapons in or near the area of activity can result in injury or death.
- Attack by or encounters with insects, reptiles and/or animals can result in injury or death.
- Encounters with plants can result in dermatitis and allergic reactions.
- Accidents or illness occurring in remote locations where there are no available medical facilities or medical attention may be significantly delayed.
- Fatigue, hypoglycemia, dehydration and other disorders may diminish my own and/or others' reaction time, thereby increasing the risk of accident.
- Fatigue, hypoglycemia, dehydration and other disorders may affect my own and/or others' sense of balance, physical coordination and ability to follow instructions.
I hereby acknowledge that I understand the description of risks herein is not complete and that unknown or unanticipated risks may result in injury, illness or death. I realize that my voluntarily assuming the risks involved, I will be solely responsible for and loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death.

Image Use

I understand that on a guided trip I may be photographed by Twin Cities Rock and Ice LLC. I agree to allow my photo, video or film likeness through any media, including any electronic media to be copyrighted and used for any legitimate purpose by Twin Cities Rock and Ice LLC or its assigns. This includes but not limited to advertising brochures, posters and website postings. I hereby waive any right of publicity or privacy that I may have in my name or likeness.

Release of Liability, Waiver of Claims and Indemnity Agreement

In consideration of being permitted to participate in any way in rock climbing and ice climbing activities, I hereby agree, acknowledge and appreciate that:
I hereby release and hold harmless with respect to any and all injury, disability, death, or loss or damage to person or property, whether caused by negligence or otherwise, the following named persons or entities, herein referred to Jason Andrew Cook and Margaret Tu, DBA Twin Cities Rock and Ice LLC.
To release Twin Cities Rock and Ice LLC from liability and responsibility whatsoever and for any claims or causes of action that I, my estate, heirs, survivors, executors, or assigns may have for personal injury, property damage, or wrongful death arising from the above activities whether caused by active or passive negligence of Twin Cities Rock and Ice LLC or otherwise. by executing this document, I agree to hold Twin Cities Rock and Ice LLC harmless and indemnify them in conjunction with any injury, disability, death, or loss or damage to person or property that may occur as a result of engaging in the above activities. This includes reasonable attorneys' fees that may incur due to the presence of any claims or actions by me, or my heirs, next of kin, assigns, or personal representatives arising from my climbing with Twin Cities Rock and Ice LLC.
By entering into this agreement, I am not relying on any oral or written representation or statements made by Twin Cities Rock and Ice LLC, other than what is set forth in this agreement. this release shall be binding to the fullest extent permitted by law. If any provisions of this release is found to be unenforceable, the remaining terms shall be enforceable. Any legal action or dispute will be in the jurisdiction of Ramsey County, Minnesota, the registered home of Twin Cities Rock and Ice LLC.
I have read this release of liability and assumption of risk agreement and I fully understand its terms and understand that I have given up legal rights by signing it and I sign freely and voluntarily without any inducement.

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.

Electronic Signature

First Name

Last Name

Date

YYYY