Rock Climbing Autonomy course (top Rope) Registration Form

Please fill out this form to confirm your registration to the course.

Contact Info
Name *
Name
Date of birth *
Date of birth
Phone *
Phone
Would you like to receive Rock Immersion's email newsletter? *
You'll receive occasional emails containing rock climbing tips as well as exclusive offers.
Date Reservation and Price Acceptation
The course is 12-hour long over 2 days.
Commitment to attend *
I understand that I'm committing to attend the course on the above dates and that I will only cancel if I really can't make it because of serious unforeseen events.
Price acceptation *
Private course (1 participant): $145 + taxes Semi-private course (2 participants): $95 + taxes per person An invoice will be sent to you by email on the day after the course. You accept the price and agree to pay the invoice online within 5 days of receiving it.
Health Status
Do you have allergies *
Do you take medication? *
Are you pregnant? *
Do you have any other health conditions that could affect your ability to participate in the course? *
For example: respiratory problems, diabetes, cardiac problems, hearing or visual impairment, physical disability, etc.
Acknowledgement and acceptation of risks
*
The risks inherent to the activity (Rock Climbing) in which I will participate are, in particular, but not limited to: Injuries due to falls to the ground (sprain, strain, fracture, head trauma and even death) either caused by bad technique or equipment malfunction; Injuries with blunt or sharp object (branches, equipment, rock, etc.); Cold, hypothermia, heatstroke or hyperthermia; Injuries resulting from accidental or other contact between individuals; Food allergy; Burns and/or other heat-induced injuries; falling rock or other objects. I am also aware that the activities offered by Antoine Bonicalzi (Rock Immersion) take place in semi-wild or natural environments that, consequently, are quite distant from medical services. This could result in long delays during an emergency requiring an evacuation and, as such, a possible aggravation of my state of health or my injury. Having taken cognizance of these risks and having had the opportunity to discuss them with a person responsible for the activity, I acknowledge that I was informed about the risks inherent to the activities and I am able to participate in the activity or the stay willingly and I accept any and all ricks that such an activity or stay can comprise. I also pledge to play an active role in risk management by adopting a preventive behaviour with regards to my own safety, and the safety of the other persons that surround me. The instructor reserves the right to exclude any person he/she deems to be a risk to himself/herself or to the rest of the group. I understand that I may leave the present activity for any reason whatsoever. The consumption of alcohol and drugs are prohibited during the activity and you also cannot be under the influence when participating in the activity. In case of emergency I authorize Antoine Bonicalzi (Rock Immersion) to provide all necessary care. I also authorize Antoine Bonicalzi (Rock Immersion) to take the decision, in case of an accident, to transport me (by ambulance, helicopter, coast guard or other) to a hospital or health care center, and this, at my own expense.
Signature
Please type your full name. This acts as your signature.
Date of signature *
Date of signature
Today's date