Climbing-Gym Belay-Certification Form
A belay-certification form for a climbing gym — climber details, gear used, top-rope and (optional) lead skills checked, hard-fail moments noted, examiner sign-off, and a re-check date.
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North Wall Climbing Co.
BELAY CERTIFICATION TEST RECORD
CLIMBER
Name: Jordan Vega Member ID: NW-22041
Test date: June 4, 2026 Examiner: Riley Chen — Lead Routesetter / Instructor
Certification type: Top-rope (TR) Device: ATC-style tube
HARNESS / KNOT / BUDDY CHECK
• Harness double-back at waist — PASS
• Harness double-back at legs — PASS
• Figure-8 follow-through — PASS
• Backup (Yosemite finish or stopper) — PASS
• Buddy check verbalized — PASS
TOP-ROPE SKILLS
• Device threaded correctly with brake side down — PASS
• Verbal climbing commands ("On belay?" / "Belay on" / "Climbing!" / "Climb on") — PASS
• Brake hand never leaves the rope during slack management — PASS
• Catch under load (test fall on TR, low/controlled) — PASS
• Lower at constant, controlled speed — PASS
• Climber off-belay and rope cleared from device — PASS
LEAD SKILLS (if applicable)
• Clip technique — partner / clip-stick demo on bouldering arête — PASS
• Feeding slack: zero short-rope, zero excessive loop — PASS
• Catch on lead-fall simulator (slack drop) — PASS
• Clip-stick / first-bolt protocol — PASS
• Soft catch under instruction — PASS
HARD-FAIL MOMENTS
(Any single hard fail — brake hand off rope, ungraceful catch, knot
miss-tied, harness uncrossed, lead-fall mismanagement — results in
"not certified." This is not "three strikes," it is "any single hard
fail.")
None.
RESULT
Certified
Re-check / refresher: June 4, 2027
EXAMINER SIGN-OFF
Riley Chen — Lead Routesetter / Instructor Signature: ____________________ Date: ____________
CLIMBER ACKNOWLEDGMENT
I confirm I belayed and was tested today under the protocols above. I
understand this belay certification is gym-specific (not portable to
other facilities), is revocable at the gym's discretion if I am
observed belaying unsafely, and that the gym's general climbing-
liability waiver remains in effect. I will re-cert by the date above.
Signature: ____________________ Date: ____________
Jordan Vega
About this template
A **belay test** is the moment a climbing gym decides whether to trust a member with another climber's life. The certification record is the gym's **audit trail** that the test happened, what was checked, and what the result was — and it is the form the gym hands the desk staff to issue a **belay sticker** that maps to the gym's access system. Three sections matter most. **Harness, knot, and buddy check** — a slipped harness or a miss-tied figure-8 is a hard fail; a verbalized buddy check ("waist buckle doubled back? knot through both tie-in points? backup tied? device threaded brake-side down? brake hand?") is the cultural practice the gym wants to embed. **Top-rope skills** — verbal commands, slack management with brake hand never leaving the rope, a catch under load, a controlled lower, and clean off-belay. **Lead skills (if certifying)** — clip technique, slack feed (zero short-rope, zero excessive loop), a catch on a lead-fall simulator, and a soft catch when instructed. The form documents **hard-fail moments** verbatim: a single hard fail (brake hand off rope, ungraceful catch, harness uncrossed, miss-tied knot, mismanaged lead fall) is **not** "three strikes" — it is "not certified, schedule a re-test." Belay certifications are **gym-specific** (a Movement-gym cert is not portable to a Touchstone-gym cert), are **revocable** if staff observe unsafe belaying after the test, and require **periodic refreshers** (commonly annual). The certification pairs with the gym's general **climbing-liability waiver** — the waiver is the liability release; the cert is the competency record. Keep the record in the member's file for the statute-of-limitations on personal-injury claims in your state.
When to use it
- Initial belay test for a new member.
- Adding lead-belay certification to an existing top-rope cert.
- Annual or biennial refresher / re-cert.
- Re-cert after a reported unsafe-belay observation.
What to include
- Climber details and member ID.
- Examiner, date, certification type, belay device.
- Harness/knot/buddy check items.
- Top-rope skills checked (and lead skills if applicable).
- Any hard-fail moments observed.
- Result and re-check date.
- Examiner sign-off and climber acknowledgment.