Bloc TLV participation confirmation form

  • Welcome to The Bloc Tel Aviv!

    We’re happy to have you with us. Climbing is an extreme and challenging sport, and therefore it is essential to be familiar with the safety rules and to complete the registration process.

  • I am filling out the form for*

  • Both options can be selected.

     

  • Child’s Details

  • Gender*
  • Does your child suffer from heart disease?*
  • Does your child experience chest pain at rest during physical activity or during routine daily activities?*
  • During the past year has your child lost balance due to dizziness?*
  • During the past year has your child lost consciousness?*
  • In the past five years has your child's doctor instructed that they may engage in physical activity only under medical supervision?*
  • Does your child have any chronic (ongoing) illness not mentioned above that may prevent or limit participation in physical activity?*
  • Does your child currently suffer or has your child ever suffered from joint problems spine or back problems or decreased bone density?*
  • Gender*
  • Does your child suffer from heart disease?*
  • Does your child experience chest pain at rest during physical activity or during routine daily activities?*
  • During the past year has your child lost balance due to dizziness?*
  • During the past year has your child lost consciousness?*
  • In the past five years has your child's doctor instructed that they may engage in physical activity only under medical supervision?*
  • Does your child have any chronic (ongoing) illness not mentioned above that may prevent or limit participation in physical activity?*
  • Does your child currently suffer or has your child ever suffered from joint problems spine or back problems or decreased bone density?*
  • Gender*
  • Does your child suffer from heart disease?*
  • Does your child experience chest pain at rest during physical activity or during routine daily activities?*
  • During the past year has your child lost balance due to dizziness?*
  • During the past year has your child lost consciousness?*
  • In the past five years has your child's doctor instructed that they may engage in physical activity only under medical supervision?*
  • Does your child have any chronic (ongoing) illness not mentioned above that may prevent or limit participation in physical activity?*
  • Does your child currently suffer or has your child ever suffered from joint problems spine or back problems or decreased bone density?*
  • Gender*
  • Does your child suffer from heart disease?*
  • Does your child experience chest pain at rest during physical activity or during routine daily activities?*
  • During the past year has your child lost balance due to dizziness?*
  • During the past year has your child lost consciousness?*
  • In the past five years has your child's doctor instructed that they may engage in physical activity only under medical supervision?*
  • Does your child have any chronic (ongoing) illness not mentioned above that may prevent or limit participation in physical activity?*
  • Does your child currently suffer or has your child ever suffered from joint problems spine or back problems or decreased bone density?*
  • Gender*
  • Does your child suffer from heart disease?*
  • Does your child experience chest pain at rest during physical activity or during routine daily activities?*
  • During the past year has your child lost balance due to dizziness?*
  • During the past year has your child lost consciousness?*
  • In the past five years has your child's doctor instructed that they may engage in physical activity only under medical supervision?*
  • Does your child have any chronic (ongoing) illness not mentioned above that may prevent or limit participation in physical activity?*
  • Does your child currently suffer or has your child ever suffered from joint problems spine or back problems or decreased bone density?*

  • Form Filler’s Details

  • Form filler gender*

  • Health Declaration

  • Do you suffer from heart disease?*
  • Do you experience chest pain at rest during physical activity or during routine daily activities?*
  • During the past year have you lost balance due to dizziness?*
  • During the past year have you lost consciousness?*
  • In the past five years has your doctor instructed you to engage in physical activity only under medical supervision?*
  • Do you have any chronic (ongoing) illness not mentioned above that may prevent or limit your ability to engage in physical activity?*
  • Do you currently suffer or have you ever suffered from joint problems spine or back issues or decreased bone density?*

  • Safety instruction video - It is mandatory to watch the video all the way through.

  • The continue button will appear at the end of the video

  • Safety and Entry Questions for The Block

  • Hello,

    In order to climb safely, it is important to make sure that you have understood and remember what was presented in the safety video. If not, please watch the video again.

  • What are the guidelines regarding climbing with headphones?*
  • Is it allowed to stand underneath other climbers?*
  • What are the guidelines regarding the use of chalk in the bouldering area?*
  • Complete the sentence: When moving between areas…*
  • How should a fall be performed correctly?*
  • Should a fall be absorbed with the hands?*
  • Is it recommended to practice falling?*
  • If I reached the end of the route, what is the safest way to get down to the mat?*

  • You answered one of the questions incorrectly. Please watch the video again to fully understand the safety rules, and then try answering the questions again.

  • participation confirmation form

  • The Bloc – Climbing Gym
    Consent Form for Participation in Extreme Activities and Voluntary Assumption of Risk
    Liability Waiver and Indemnification Agreement

    I, the undersigned, hereby request, of my own free will, to participate in climbing activities and/or to approve the participation of one or more of my minor children in climbing activities.

    It is fully understood by me that the activities in question are inherently dangerous activities and involve various risks. It is known and understood by me that a participant in these activities is exposed to these risks and others, and by approving participation in these activities, I voluntarily assume full responsibility.

    I hereby agree to release and discharge The Bloc – Climbing Walls Ltd. and/or its owners and/or its employees and/or anyone involved in the activity from any physical, mental, or property damage that may be caused to me and/or to my son/daughter.

    Furthermore, The Bloc – Climbing Walls Ltd. and/or any of the parties listed above shall not be liable for any damage or property loss that may be caused to the participant in the activity, in any place where the participant uses the knowledge acquired from The Bloc – Climbing Walls Ltd., including damage resulting from negligence. I hereby release The Bloc – Climbing Walls Ltd. from any and all liability.

    The dangers inherent in this activity have been explained to me, and I hereby assume any and all risks of injury, paralysis, and/or death that may be caused to the participant in the activity.

    I acknowledge that it is the participant’s duty to learn the rules of the facility and the code of conduct and to act accordingly. It has been explained to me, and I confirm that I understand, that a person who does not act in accordance with these rules constitutes a danger to themselves and to others, and that any injury resulting from such conduct shall not be the responsibility of The Bloc – Climbing Walls Ltd.

    Moreover, I agree that in the event a third party is injured as a result of my actions and/or the actions of one of my children participating in the activity, within the activity area or in connection with The Bloc – Climbing Walls Ltd., I shall indemnify and assume full and exclusive responsibility toward The Bloc – Climbing Walls Ltd., its owners, and its employees.

    I have read and understood the rules of the activity, and we agree to act in accordance with them. I and/or my participating child(ren) are in a state of health suitable for the nature of the activity and do not suffer from any physical and/or mental condition that may impair judgment, and are not under the influence of alcohol, drugs, or any medication that affects decision-making ability.

    I acknowledge that this document constitutes a binding contract. I have read this agreement carefully and sign it of my own free will.

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