Dixie State University

HPC Climbing Wall Informed Consent for Minors and their parent

HPC Climbing Wall Informed Consent for Minors and their parent

This is informed consent form for minors, which identifies risks of the utilizing the DSU HPC Climbing Wall and consent form for parents/guardians.

Parents or Guardian, read and sign this section: I have been informed of the nature of the Climbing Wall activity which my minor child wishes to participate in. I recognize that the Climbing Wall activity may involve following risks:

  1. Risks involved in physical activity. These activities may include walking, running, climbing, repetitive lifting, and other strenuous activity. Physical activity may also include the risk of injury such as slips, falls, cuts, scrapes, lacerations, burns, sprains, tears, concussion, fractures of bones, bleeding, bruising, hemorrhage, infection and discount such pain, nausea, dizziness, or other illness or sickness.
  2. Risks involved in climbing and bouldering. These include but are not limited to falls from height and attendant impact with the floor or other surfaces, which may include the possibility of death, serious neck or spinal injury, complete or partial paralysis, and brain damage.
  3. Risk of equipment failure. Equipment used to malfunction, break, or fail, despite reasonable care, maintenance and use.

I hereby freely assume risks which may be associated with or result from the participating in Climbing Wall activities. It also includes & not limited to: travel to and from, instruction, participation, and competition.

I further agree to release the State of Utah, Dixie State University, their officers, employees, agents, contractors, and volunteers (releasees) from any and all liability, claims, demands, actions, loss, claim, damage, injury, illness, or harm (Claims) to me of any kind or nature arising out of participation in the Activity including where claims occur due to the negligence of releases.This Agreement shall be governed by the laws of the State of Utah and any dispute arising out of the Activity or Agreement shall have venue in the courts of Washington County, Utah

I state that my minor child is free from any known heart, respiratory or other health problems that could prevent her or him from safely participating in the activity. I consent to the participation of my minor in the Climbing Wall activity.


Consent is expressively given, in the event of injury, for any emergency aid, anesthesia, and/or operation, if the opinion or DSU personnel or responding medical professionals.

Participating minor child, read and sign this secion: I desire to participate in the Activity above. I agree to familiarize myself with the activity, what is required of me, rules of conduct and safety equipment. I agree to follow proper operating procedures including safety procedures as outlined by the activity leader, plus any directions given by DSU personnel. I agree to follow the rules of conduct and use the provided safety equipment.