REGISTRATION FORM
Unsupervised Climbing at DMU Climbing Wall
Participation Statement
“The British Mountaineering Council recognises that climbing and mountaineering are activities with
a danger of personal injury or death. Participants in these activities should be aware of and accept
these risks and be responsible for their own actions and involvement.”
Personal Details
Title
Please complete the form in BLOCK CAPITALS.
First Name
Male / Female
Surname
Date of Birth
Address
Post code
Daytime Tel. No.
Evening Tel. No.
Occupation
E-mail address
How did you hear about DMU Climbing wall
Conditions of Registration
If you are under 16 years of age DO NOT fill in this form! Please ask at Reception for the correct form.
Once you have read the Terms and Conditions and Climbing wall Guidelines of the climbing wall, you must
answer the following questions by writing either “YES” or “NO” in the box provided then sign the declaration at the
bottom of the form. Only climbers who give satisfactory answers to the questions will be registered and allowed to
climb unsupervised.
Are you over 16 years of age?
..........................................................................................................
Have you read and understood the Conditions of Use and Rules of the centre?
* Can you put on a climbing harness correctly?
..............................
................................................................................
* Can you attach a rope to your harness using a suitable climbing knot?
..........................………….
* Can you use a belay device to secure a falling climber and lower a climber from the wall?
Do you require instruction in any of the above three techniques (marked *)?
...........
...................................
Do you understand that failure to exercise due care could result in your injury or death? ................….
Do you have any questions regarding the application of the Conditions of Use or the Rules?
Do you agree to abide by the Rules of the climbing centre?
Declaration of fitness
Declaration of fact
.............................................…………..
I certify that to the best of my knowledge, I do not suffer from a medical
condition which might have the effect of making it more likely that I be
involved in an accident which could result in injury to myself or others.
I also confirm that the above information is correct and if any information
changes I will notify the centre:
Signature
Date
THIS PART TO BE FILLED IN BY DMU STAFF
Registration Number
Amount Paid for Registration
Signature
.........
Registration Type
£ 20
Receipt number
Date
Full Induction
Induction Card
Please read through and initial next to relevant boxes to say we have covered all of the below areas, if you
have any questions or concerns please speak to the climbing wall instructor.
USER
Safety brief given by instructor understood
Knowledge about the wall ( Routes, grades and height)
Warm up (Traversing, games)
Understanding of how kit is checked (harness, helmets, Belay devices, ropes and
Initial
Karabiners)
How to put kit on and adjust (harness and helmet)
Was Shown how to tie a figure of eight with stopper knot
Was shown how to tie into harness
Was shown how to connect and work the belay device
Was shown how to belay and lower a climber on the climbing wall
Was shown how to use the Auto-Belay device
Please fill in the boxes below and if there are areas that need work DO NOT sign them off and put a
comment in the box at the bottom detailing areas of concern. The more detail the better to help the next
instructor taking the individual’s session.
INSTRUCTOR
Can check kit and knows what to look for
Can put kit on correctly and adjust to fit
Can tie a figure of eight and stopper knot competently
Can tie into a harness competently
Can connect and work the belay device
Can show good belaying techniques and lower a climber from the wall
Induction
Stage-
1
/
Staff initials
/
2/
Staff initials
/
3/
Initial
Staff initials
/
COMMENTS
PLEASE SIGN WHEN PASSED AS COMPETENT
Climber-................................. Date................ Instructor...............................