Parks Pass Application Form PDF Details

Are you planning a trip to visit a national or state park? If so, obtaining a Parks Pass is necessary and beneficial for many reasons. With your Parks Pass, you will receive exclusive access to amenities and activities throughout the various parks that would not be available otherwise. Completing an application form is the first step in getting started on the process. Here we provide an overview of what to expect when applying for your Parks Pass.

QuestionAnswer
Form NameParks Pass Application Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnys access pass, nys parks access pass, individual access pass, new york state pass application

Form Preview Example

What is the Individual

Access Pass?

The IndividualAccess Pass permits a resident of New York State with a disability, as defined in the

attached application,free or discounted use of parks,

historic sites,and recreational facilities operated by the New York State Office of Parks, Recreation and Historic

Preservation and the NewYork State Department of Environmental Conservation.For a description of these facilities visit www.nysparks.com and www.dec.ny.gov.

The pass holder may have free or discounted use of facilities operated by these offices, for which there is

normally a charge — for example,parking,camping, greens fees,swimming.

The IndividualAccess Pass is not valid for waiver of fees such as those for seasonal marina dockage,group

camp or cottage rental,performing arts programs, consumables (i.e. firewood, electric, or gas), campsite/

cabin amenities,reservations and registrations as well as some services or locations operated by an outside concessionaire.

Access Pass qualifications and requirements are

described within the application.

TheAccess Pass includes an expiration date.It is the responsibility of the pass holder to reapply in order to obtain a new pass. There is no renewal process.

The Office of Parks,Recreation and Historic Preser-

vationisauthorizedtocollectthisinformationbySection

3.09of the Parks,Recreation and Historic Preservation

Law.It will be used to determine your eligibility and to process your application.If the information you provide is not complete,it will not be possible to process your

application.The information will be maintained by the Regional Programs and Services Bureau, State Parks, Albany, NY 12238, 518-474-2324, TTY/TDD through 711 Relay Service.The information may also be used

to contact you about this and other programs of the NewYork State Office of Parks,Recreation and Historic

Preservation.

To ensure that your application can be approved for processing please be sure that all of the items below are included when submitting

your application.

√Completed all theApplicant Information in Part One

√Enclosed a copy of your current NewYork

State Driver License, Non-Driver Identification

Card,or a copy of your NewYork State tax return form IT 201 or IT 150

√Enclosed a passport size photo (2” x 2”)

√Signed and dated theAuthorization and

Certification

√Enclosed the proper organization certification

OR

Your physician completed all the information in PartTwo.

•This application cannot beprocessedonsiteatanylocation.

Mail this application, enclosing all

required materials to:

Access Pass

NewYork State Parks

Albany,NY 12238

Please allow 2 - 4 weeks for processing

of this application

For questions contact our office during

regular business hours.

518-474-2324

TTY/TDD through 711 Relay Service

ACCESS PASS NEW YORK STATE PARKS ALBANY, NEW YORK 12238

INDIVIDUAL

ACCESS PASS

Application

INDIVIDUAL

 

 

ACCESS

 

 

 

PASS

 

 

 

 

 

PHOTO

EXPIRATION

 

 

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

1/1/2014

 

NAME:

 

 

 

 

 

 

 

JANE

 

 

 

PASS ID

 

 

PUBLIC

 

 

# 93631-

 

 

 

 

 

 

 

XX-1

 

INDIVIDUAL

 

 

PHOTO

ACCESS

 

 

 

 

 

 

 

 

 

PASS

 

 

 

 

 

 

 

 

 

DATE:

1/1/2014

 

EXPIRATION

 

 

 

 

PUBLIC

 

 

NAME:

JANE

 

 

 

 

-1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-XX

 

PASS

ID # 93631

 

 

 

 

 

 

 

 

 

 

 

 

 

nysparks.com

www.dec.ny.gov

on recycled paper

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed

IndividualAccess

 

Oh,Ranger!

Pass Guidelines

NY State ParksApp

 

An Equal Opportunity/Affirmative Action Agency Program

RS 8 5/16

INCOMPLETE ACCESS PASS APPLICATIONS WILL BE RETURNED

PART ONE: Personal Information APPLICANT MUST COMPLETE SECTIONS A THROUGH D

A. APPLICANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Code ______

 

CertificationVerification:

 

 

Birth Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 Digits of Social Security No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved By

______

1

2

 

 

3

4

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

X

X

 

 

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Denial Code

(s) _____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Denied By

______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

StreetAddress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City orTown

 

 

 

 

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NY

 

 

 

 

 

 

MailingAddress (if different than street address)

 

 

 

 

 

 

 

 

 

City orTown

 

 

 

 

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

Email Address (optional):___________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please provide your email if you would like to receive NY State Parks program information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. RESIDENCY REQUIREMENT

Applicant must provide a copy of one of the following which must be in the name of the applicant or, in the case of a minor, in the name of the parent or legal guardian.

•A copy of a currently valid New York State Driver License or Non-Driver Identification card (do not send original).

OR

•A NewYork State tax return (IT 201 or IT 150) for the current,or if not yet filed, the preceding tax year (financial information may be hidden).

C. PHOTO

TAPE a current photo of the applicant;full-face view, passport size (2" x 2") with the name writ-

ten on the back.Do NOT staple,glue,paperclip, or place tape on the front of the photo. Digital photos may be used but photocopies of photos cannot be accepted.

*This photo will be affixed to your pass.

D. AUTHORIZATION & CERTIFICATION

I authorize the release of any pertinent medical information needed to process this application. I certify that the information provided is true to the best of my knowledge and believe and understand that any person who knowingly files a statement containing any materially false information, or conceals for the purpose of misleading,information concerning any fact material thereto,commits a fraudulent act. ANY FALSE STATEMENT MADE HEREIN IS PUNISHABLE AS A CLASS “A” MISDEMEANOR PURSUANT TO SECTION 210.45 OF THE PENAL LAW.

 

 

 

Applicant/Parent/Legal Guardian Signature

 

Date

 

Parent or Legal Guardian must sign for applicants under 18 years of age

PART TWO: Certification

APPLICANT MUST COMPLETE SECTION A OR PHYSICIAN MUST COMPLETE SECTION B

PLEASE NOTE:The following are NOT acceptable proofs of disability:

Certifications from the following are NOT acceptable proofs of disability:

•

NewYork State Handicapped Parking Permit

• NewYork State Employees Retirement System

•

Medicare or Medicaid Card

• NewYork StateWorkers Compensation Board

•

Social Security Statement

 

• Veterans Administration medical treatment card

• Insurance Company

A.ORGANIZATION CERTIFICATION: Attach certification of one of the following issued within ONEYEAR of this application’s date.

•BL Personwhoisblind:Certification from the NewYork State Commission for the Blind and Visually Handicapped that the applicant has a central visual acuity of 20/200 or less or limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than twenty degrees in the better eye with the use of a correcting lens.

•VA Veteran who has a disability: Certification from the United StatesVeterans Administration or the NewYork State Division ofVeterans Affairs that the appli-

cant is a veteran of the wars of the United States with a 40% or greater service connected disability as certified by the United States Veterans Administration,

or who has at any time been awarded by the Federal government an allowance towards the purchase of an automobile or who is eligible for such an award. *Individual will receive Lifetime Liberty Access Pass.

•DD Person who has a developmental disability: Certification from the New York State Office for People with Developmental Disabilities that the applicant is eligible to receive services from a program they license,operate,certify or fund.

•MH Person who has a mental disability: Certification from the NewYork State Office of Mental Health that the applicant is receiving services from a program they license,operate,certify or fund.

B.PHYSICIAN CERTIFICATION: To be completed by the physician only if the Organization Certification in Section A is not provided. Physician must select the applicable statement(s) and complete certification below within 6 months of the application date. A disabling condition is acceptable only if it causes one of the functional limitations listed below. *Handwriting other or additional conditions will not be accepted.

____ AM Person who has an amputated arm or leg: has a fully or partially

amputated or congenitally absent arm or leg,excluding the extremities of the hands (fingers) and feet (toes).

____ BL Person who is blind: has a central visual acuity of 20/200 or less or

limitation in the field of vision such that the widest diameter of the visual field subtendsananglenogreaterthantwentydegreesinthebettereyewiththeuse of a correcting lens.

PHYSICIAN'S INFORMATION

____ DF Person who is deaf: has profound hearing loss causing the person to

primarily rely on visual communications (sign language, lip reading, gestures) and assistive technology.

____ WC Person who is non-ambulatory: has a permanent disability which pre-

vents them from being able to walk and therefore requires the use of a wheel- chair at all times.

First Name

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUFFIX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

StreetAddress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City orTown

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

 

License Number

NY

I certify the following:the applicant is disabled as indicated by my selection of the applicable qualification;I am currently licensed and practicing in NewYork State;the above information is true to the best of my knowledge; I believe and understand that any person who knowingly files a statement containing any materially false information, or conceals for the purpose of mislead-

ing,information concerning any fact material thereto,commits a fraudulent act. ANY FALSE STATEMENT MADE HEREIN IS PUNISHABLE AS A CLASS “A” MISDEMEANOR

PURSUANT TO SECTION 210.45 OF THE PENAL LAW.

Physician’s Signature: _______________________________________________ Date: _____________________ Physician’s Stamp:

How to Edit Parks Pass Application Form Online for Free

In case you would like to fill out individual access pass, you don't have to download any kind of applications - simply try our online tool. To maintain our tool on the cutting edge of practicality, we aim to adopt user-driven features and improvements on a regular basis. We're always happy to receive feedback - play a pivotal role in reshaping PDF editing. For anyone who is seeking to get started, this is what it will require:

Step 1: First of all, access the editor by pressing the "Get Form Button" at the top of this site.

Step 2: With our online PDF tool, you can actually do more than merely fill out blank fields. Try each of the functions and make your forms seem high-quality with customized textual content put in, or adjust the original input to excellence - all supported by an ability to insert stunning images and sign it off.

Completing this document needs attention to detail. Make sure all required fields are done correctly.

1. To get started, once filling in the individual access pass, beging with the part that features the subsequent blanks:

Part no. 1 in filling out nys parks access pass

2. Just after filling out the last step, go to the next part and enter all required particulars in all these blanks - ApplicantParentLegal Guardian, Date, PART TWO Certification APPLICANT, PLEASE NOTE The following are NOT, Certifications from the following, A ORGANIZATION CERTIFICATION, or who has at any time been, B PHYSICIAN CERTIFICATION To be, AM Person who has an amputated, and DF Person who is deaf has.

Date, AM Person who has an amputated, and A ORGANIZATION CERTIFICATION inside nys parks access pass

It's very easy to make errors while filling out your Date, and so you'll want to take another look before you'll submit it.

3. The following section will be focused on AM Person who has an amputated, DF Person who is deaf has, PHYSICIANS INFORMATION First Name, Street Address, City or Town, Last Name, SUFFIX, State NY, Telephone Number, Zip Code, License Number, I certify the following the, and Physicians Signature Date - fill out every one of these empty form fields.

Part # 3 for filling in nys parks access pass

Step 3: Make sure your information is accurate and then simply click "Done" to complete the project. Download the individual access pass the instant you sign up for a free trial. Easily gain access to the document from your personal account page, with any modifications and adjustments automatically synced! FormsPal is committed to the privacy of all our users; we make sure all personal information entered into our tool stays secure.

Parks Pass Application Form isn’t the one you’re looking for?

Related Documents