Release Of Liability / Assumption Of Risk Form (Page 6 of 7) in pdf

Release Of Liability / Assumption Of Risk Form Page 6

Program Questionnaire

Program & Date:____________________________

Please have each participant complete this form.

1. Have you participated in this activity before? _________ Have you had instruction?________

Where? ___________________________________________________________________

2. How would you rate yourself?

Beginner

Advanced-Beginner

Intermediate

Advanced

Ice/Rock Climbing/Mountaineering: Please circle your highest ability & comfort level (if no

experience, leave blank):

• Toproping easy to moderate terrain

• Following multi-pitch routes (circle): Rock Difficulty: _____ or Ice: Grade 1-2 Grade 3-4

Grade 5+

• Lead climbing

• Particpated in mountaineering work shop

(Rope team travel, crevasse rescue, self arrest, Fix line ascending/descending)

Skiing: Please circle your highest ability & comfort level:

• Blue square terrain; wide open groomed trails with occasional bumps & open glades

• Blue-black terrain and moderately open glades & bumps

• Black diamond terrain; variable terrain and tighter glades

• Double-black terrain and moguls, tight glades, and un-groomed, possibly icy conditions

Avalanche Education: Please circle your highest ability & comfort level (leave blank if none):

• Avalanche Awareness

• Level I course

• Level II Course

• Certified Level III

If circled any above please indicate where you received your training and through what organization

_______________________________________________________________________________.

3. What would you like to accomplish today (goals)?

Notes: (list favorite ski descents, climbing routes, or other information we should know about you!)

Petra Cliffs Mountaineering School

105 Briggs Street

Burlington, VT 05401

(802) 657-3872 Toll-free: (866) 657-3872

Fax: (802) 657-3877

Release Of Liability / Assumption Of Risk Form Page 6