You can copy and paste the following text into the body of your email message, complete the form and send to "rockwall@ahc3.org". You will need to sign the 'GENERAL RELEASE, WAIVER AND INDEMNITY AGREEMENT', 'CLIMBING WALL RELEASE', and, if required, the 'PARENTAL CONSENT' before you or your child is enrolled to the program. Copies of these agreements are included here.

AGOURA HILLS / CALABASAS COMMUNITY CENTER REGISTRATION FORM

Adult Name:
Address:
City & Zip:
Home Phone:
Work Phone:

Class Name:
Participant Name:
Sex of Participant:
Birthdate:
Fee:

Method of Payment:
__ Cash
__ Check

__ Mastercard*
__ Visa*

*Card number:
Expiration Date:

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Please indicate if this participant has special needs:
__ Visually Impaired
__ Hearing Impaired
__ Mobility Impaired
__ Learning Impaired
__ Other Needs:

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GENERAL RELEASE, WAIVER AND INDEMNITY AGREEMENT
(Must be signed before program. If you are sending this form as an attachment to an email, you will have to sign the Agreement prior to enrollment)

I certify that I am volunteering to participate in the above program(s). I understand that 'participation' in the Program may include preparing for, traveling, receiving instruction, and engaging in the Program. I further certify that I am in good health and have no physical or other impediment which would endanger me while participating in the Program. I realize that by participating in this Program I will be exposed to a risk of injury or death. In consideration of permitting me to enroll in and participate in the Program, I agree (on behalf of myself, my heirs, executors, administrators, and assigns) to release, discharge, waive and relinquish the Joint Powers Authority (and its officers, agents, employees, and volunteers) from any and all liabilities, claims, or actions for personal injury, property damage, or wrongful death which arise out of or relate to the Program, whether or not the liability, claim, or action arises out of negligence or carelessness on the part of the Joint Powers Authority (or its officers, agents, employees, and volunteers). I further agree (on behalf of myself, my heirs, executors, administrators and assigns) to indemnify, defend and hold harmless the Joint Powers Authority (and its officers, agents, employees, or volunteers) from any and all liabilities, claims or actions for personal injury, property damage, or wrongful death which arise out of or relate to my participation in the Program whether or not the liability, claim or actions arises out of negligence or carelessness on the part of the Joint Powers Authority (or its officers, agents, employees, or volunteers). I understand the dangers incidental to participating in the Program and the need for safety precautions. I have read this General Release, Waiver and Indemnity Agreement and am fully aware of the legal consequences of signing it.

CLIMBING WALL RELEASE: I acknowledge and agree that the sport of rock climbing and the use of The Agoura Hills/Calabasas Community Center climbing wall has inherent risks. I have full knowledge of the nature and extent of all the risks associated with rock climbing and the use of the climbing wall:

          Injuries from climbing and belaying can result in paralysis or death
          No safety equipment can guarantee risk free climbing
          Safety equipment is not failure proof: the possible failure of safety equipment is an inherent risk of climbing or belaying

I am in good health and have no physical limitations which would prevent my safe use of the climbing wall and I am not under the influence of drugs or alcohol, which would impair my ability to climb safely.

I understand that I climb at my own risk without supervision, and I alone am responsible for my safety.

Signature:

Name:

Date:

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PARENTAL CONSENT: (To be completed and signed by parent/guardian if applicant is under 18 years of age). I certify that I am the parent or legal guardian of the above participant and that I am entitled to his or her custody and control and I do hereby give permission for the Child to participate in the above activity. I further certify that the Child is in good health and has no physical or other impediment which would endanger him or her while participating in the Program. I realize that by participating in this program, the Child will be exposed to a risk of injury or death. I hereby execute the above Agreement, Waiver, and Release on his/her behalf. I understand the dangers incidental to participating in the Program and the need for safety precautions and I have discussed the dangers of the program and the need for safety precautions with the Child.

Signature:

Name:

Date:

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Walk-In Registration Hours:
          Monday-Friday 6am-10pm
          Saturday 7am-7pm
          Sunday 7am-6pm

Location:
Agoura Hills/Calabasas Community Center 27040 Malibu Hills Rd Calabasas, CA 91301