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DATE______________ SCHOOL: NORTHEAST__________ MCC__________BC_______
THE ROCK C4YD REGISTRATION FORM
Student Information
Name: __________________________________ Birthday (MM/DD/YY): _______________________
Sex: Male / Female
Current Age:____________
Current Grade: ____________
Home Phone: ___________________________Cell Phone: ____________________________________
Home Mailing Address: ________________________________________________________________
Street
City
St.
Zip
Email Address: _______________________________________________________________________
Demographics
Demographics Disclaimer: Completing this section is completely voluntary, and all information recorded in this section will be kept
confidential. The information will be used by The ROCK for statistical purposes, program assessment and planning, and may aid
in securing program funding through grants. Your participation in this section is greatly appreciated.
Race/Ethnicity:
African American/Black
Hispanic/Latino
Asian/Pacific Islander Other
American Indian/Alaskan Native
White
Do you have a disability? Yes
Do you qualify for free or reduced lunch?
Yes
No
No
Parent/Guardian Information (please complete both)
(With whom do you live?): Mother_________ Father_________ Guardian (Specify) ______________________
Name: _____________________________________________________________________________________
Home Phone #: ___________________________Cell Phone ___________________________________
Home Mailing Address: ________________________________________________________________
(If different then above)
Street
City
St.
Zip
Email Address: _______________________________________________________________________
Additional Parent/Guardian or Emergency Contact Information
(With whom do you live?): Mother_________ Father_________ Guardian (Specify) ______________________
Name: _____________________________________________________________________________________
Home Phone: ___________________________Cell Phone: ____________________________________
(If different then above)
Street
City
St.
Zip
Email Address: _______________________________________________________________________
MEDICAL INFORMATION
Please specify any conditions, illnesses or disabilities that might alter participation in activities, so that we may better accommodate you
Allergies (Food, Insect, Medications): _______________________________________________________________________________
Medications (List any current medications and their purpose): ____________________________________________________________
Chronic Physical Illnesses (Diabetes, Epilepsy, Asthma): _______________________________________________________________
Behavioral or Emotional Conditions (ADHD, Oppositional Defiant Disorder, Depression): ____________________________________
Physical Conditions: ____________________________________________________________________________________________
Please complete both sides 
AUTHORIZATIONS
I give my permission to The ROCK to transport my student during program times.
Yes _____
No _____
I give permission to view movies with a PG-13 rating at The ROCK.
Yes______
No_____
I give permission for The ROCK Staff to administer basic first aid to my teen in the
case of a minor injury.
Yes______
No _____
I give permission for my teen to swim at MCC under the supervision of trained life
guards and ROCK staff.
Yes______
No _____
I give permission for my teen to climb the rock wall at MCC as well as the 24’ mobile
rock climbing wall owned by The ROCK. (see attached form for MCC rock wall).
Yes______
No _____
Yes______
No_____
I give permission for my teen to play M rated games at The ROCK. (M rated games
are only played at certain times and are chosen carefully by ROCK Staff.)
RELEASE OF LIABILITY STATEMENT – ROCK C4YD
Participants and their parents understand that involvement under the supervision of The ROCK Center for Youth Development
may entail risk of injury or harm to the Participant and agree that risk is fully assumed by the Participants and/or their parents. In
addition, Participants agree to hold The ROCK Center for Youth Development harmless for, from and against any and all liability,
damages and claims of any kind, known and unknown, which may be connected with, result from, or arise out of participating in
activities at the ROCK Center for Youth Development. This includes, but is not limited to, claims involving economic loss,
illness or medical condition, accidental injury or death.
If you participate in ROCK programs and events there is a possibility you will be photographed and/or video taped and your
picture may be used for promotional purposes. By your continuing participation in the programs and events you agree to this.
By signing below, I acknowledge that I have read and understand the above statements.
Signature of Parent/Guardian: ________________________________________
(if younger than 18)
Date: __________________
The ROCK Mission
The mission of The ROCK Center for Youth Development is to provide every youth with unconditional love
support, respect, a safe environment, guidance and a model of healthy behavior.
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You are not allowed to come and go from The ROCK. Once you leave The ROCK you will not be allowed back in unless special
arrangements have been made.
Stay in afterschool designated areas.
You are responsible for your own items and The ROCK cannot replace them. Please do not leave items of value lying around.
Students can expect to follow the same rules as they do in school.
**If there are multiple releases on file for this student, the most recent one will be used.
**The afterschool program is free to all participants. There will be opportunities to donate money and/or items/snacks throughout the
year.
The ROCK Center for Youth Development is a 501(c)3 non-profit organization. The ROCK was formed in 2000 and is a unique
organization in the Midland Community. The purpose of The ROCK is to build positive relationships with 6th through 12th grade
students and to make a positive impact on their lives: in order to create a better community, a better country and a better future for
everyone. The ROCK focuses on reaching teens through relevant, quality programming and activities.
Midland Community Center
2205 JEFFERSON AVE
MIDLAND, MICHIGAN 48640
www.MyMCC.org
PHONE: (989) 832-7937
FAX: (989) 835-7290
AGREEMENT FOR USE OF ROCK CLIMBING EQUIPMENT & RELEASE OF LIABILITY
Name _____________________________________________
Date of Birth _________________
Address ______________________________________________________________________________
City ________________________ State ______
Zip Code ___________ Phone _______________
Emergency Contact ______________________________________________
Phone _______________
PLEASE READ: The form is intended to remind leaders and participants of the seriousness of attempting climbing activities with an
old or pre-existing injury, heart condition or other condition which might be aggravated by the event. This information will remain valid
for one year. This document and information will remain confidential.
1.
2.
3.
4.
5.
6.
7.
Any pre-existing injuries (ankle, knee, neck, etc.) that might be
aggravated by participating?
Taking any current medications?
Any heart problems?
Do you have high blood pressure?
Do you have allergies? (food, bees, insects, medications, etc.)
Do you have any physical limitations?
Your current level of activity at home?
YES
YES
YES
YES
YES
YES
LOW
MED
NO
NO
NO
NO
NO
NO
HIGH
If you answered YES to any of these questions above please discuss with the climbing staff.
In addition to please include any information that you feel is relevant:
_________________________________________________________________________________________
______________________________________________________________________________________
PLEASE READ: I am aware that participating in rock climbing and artificial wall climbing carries certain risks. I choose to participate in
this activity with full knowledge of the dangers involved, and hereby agree to accept full responsibility for my own safety. The Center
shall not be liable for any damages arising from personal injuries I sustain in, on, or about the premises of the Center. I fully release
and discharge the Center, its affiliated entities, its employees, its contractors and its agents from any and all claim, demands, damages,
causes of action, present or future, whether they be known, anticipated, or unanticipated, that may result from or arise out of my use or
intended use of the climbing facilities and/or equipment. Further, I agree that any equipment that I use on the premises or borrow or
rent from the Center during any climbing or other activity, I use at my own risk. The Center shall not be liable for any loss, damage or
injury resulting from my use of the equipment. The Center makes no warranties regarding said equipment. The terms of this
Agreement shall also bind my family members, heirs, personal representatives, and trustees. I understand that this is a binding
contract that supersedes any other agreement or representations. If I wish to cancel this contract, I must notify the Center in writing,
and any such cancellation shall only be prospective. I give my permission to the Midland Community Center to take photographs and
use them for Midland Community Center publications and advertising. Please read policies and rules on reverse side before signing.
I am legally competent to read and sign this release.
Participant Signature: __________________________________________
Date: ________________
If Participant is under 18 years of age, participant’s parent or legal guardian must sign, assuming all of the obligations, responsibilities,
and liabilities otherwise assumed by participant.
Parent/Guardian Signature:_______________________________________
Date:_________________
Midland Community Center’s Rock Climbing Wall Policies and Rules:
1. Staff is responsible for teaching participants how to belay and maintaining the safety of the
climbing wall.
2. Anyone 18 years of age or younger must have their waiver signed by a parent or guardian.
3. Participants 15 years of age and younger are not allowed to belay.
4. For your own safety, all climbers shall pass a safety check and complete a waiver prior to using the
wall.
5. Bare foot climbing is prohibited.
6. Our climbing wall is drug free and alcohol free. Participants will be asked to leave if there are under
the influence of drugs or alcohol.
7. The staff has the right to revoke climbing privileges if climbers use poor judgment.
8. The staff is not responsible for lost or stolen items.
9. Absolutely no instruction is allowed in the climbing wall except from the climbing staff.
10. While bouldering (climbing without a belayer or harness) participants must keep their feet below
the red line.
11. Only approved equipment can be used in the climbing wall. If participants bring their own
equipment and it is not up to standard they must use the climbing wall’s equipment.
12. All participants must tie directly into their harness with a rewoven figure eight knot.
13. All participants are encouraged to warm up and stretch before climbing to reduce the risk of injury.
14. All belayers must be standing within four feet of the climbing wall.
15. If belaying with a figure-eight device, climbers must use it as a belay device – not as a rappel
device
16. All belayers must attach their harness to a designated ground anchor as a backup only.
17. Climbers must use harnesses only – No Swami Belts allowed.
18. Immediately report any accidents or injuries to the climbing staff.
19. Landing zones of all climbs must be clear of clutter. Personal belongings should be kept in
designated areas.
20. Loud and offensive behavior such as shouting and swearing will not be tolerated.
21. While wearing an MCC harness, wet clothing is not allowed.
22. Disregard of these rules or unsafe actions can result in immediate loss of climbing privileges.