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Harriman/ Bear Mountain State Park – Powerlinez Area

Palisades Interstate Park Commission

Acknowledgement of Risk - Climbing Permit

*Valid for 2020 Only

The holder of this permit climbs with full knowledge of the dangers involved and assumes any risk of injury and death caused by the inherent dangers of the sport. It is understood that neither the Palisades Interstate Park Commission nor the Torne Valley Climbers’ Coalition maintains the rocks, cliffs or other natural features of the terrain. They do not provide supervision or instruction, do not approve qualifications or certify instructors in any manner and are not responsible for the climbing protection on the cliffs (for example: bolts, pitons, rappel slings, rings).

• The holder of this permit recognizes the natural hazards of forested, mountainous areas and assumes all risk of personal injury caused by such hazards.
• The holder acknowledges that skill and training are essential in rock climbing.
• Be aware of the existence of other climbers and hikers and do not throw or kick any objects from cliff.
• Use service roads and marked access trails only; carry out all litter; do not disturb plants or wildlife.
• Dogs must be kept on leashes, six feet or less, at all times.
• Use clean climbing techniques only. The use of bolts and pitons are strictly prohibited.
• No fires, camping, motor vehicles, radios, glass containers or alcohol.

First Climber's Name

First Name*

Last Name*
First Climber's Date of Birth*
First Climber's Signature*
Second Climber's Name

First Name*

Last Name*
Second Climber's Date of Birth*
Third Climber's Name

First Name*

Last Name*
Third Climber's Date of Birth*
Fourth Climber's Name

First Name*

Last Name*
Fourth Climber's Date of Birth*
Fifth Climber's Name

First Name*

Last Name*
Fifth Climber's Date of Birth*
Sixth Climber's Name

First Name*

Last Name*
Sixth Climber's Date of Birth*
Seventh Climber's Name

First Name*

Last Name*
Seventh Climber's Date of Birth*
Eighth Climber's Name

First Name*

Last Name*
Eighth Climber's Date of Birth*
Ninth Climber's Name

First Name*

Last Name*
Ninth Climber's Date of Birth*
Tenth Climber's Name

First Name*

Last Name*
Tenth Climber's Date of Birth*
Parent or Guardian's Email Address

Email*
If you leave this checked, we'll send you TVCC newsletters by email.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*

Zip Code
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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