First Name
Last Name
Date of Birth
Phone Number
Street Address
City/Suburb
State/Province
Postal/Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Do you have any medical conditions or injuries that may affect your ability to participate in rock climbing?
If yes, please specify.
Are you currently taking any medications?
If yes, please list them.
Do you have any allergies (e.g., to pollen, insects, or medications)?
If yes, please specify.
Do you have any fears or phobias (e.g., heights, falling, confined spaces)?
If yes, please describe.
What is your current level of physical fitness?
Beginner
Intermediate
Advanced
Do you engage in regular physical activity or exercise?
If yes, please describe your routine.
Have you ever taken a rock climbing course before?
If yes, please provide details (e.g., location, duration, level).
What type of rock climbing are you interested in?
Indoor climbing
Outdoor climbing
Bouldering
Top-rope climbing
Lead climbing
Multi-pitch climbing
Other:
What are your goals for this course?
Learn basic climbing techniques
Improve climbing skills
Gain confidence in climbing
Prepare for outdoor climbing
Other:
Are you interested in obtaining any certifications (e.g., belay certification)?
Do you have your own climbing equipment?
If yes, please list the equipment you own.
Are you comfortable using provided equipment?
Do you have any preferences for the type of climbing environment (e.g., indoor gym, outdoor crag)?
What is your preferred schedule for the course?
Weekdays
Weekends
Flexible
How many hours per week can you dedicate to the course?
Do you have any time constraints or scheduling conflicts?
If yes, please specify.
Do you understand that rock climbing involves inherent risks, including the risk of injury or death?
Are you willing to follow all safety instructions and guidelines provided by the instructor?
Do you consent to emergency medical treatment if necessary?
Is there anything else you would like us to know about your background, goals, or concerns?