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SOUTHERN CHESTER COUNTY SPORTSMEN’S
AND FARMERS’ ASSOCIATION, INC.

720 Sportsmen s Lane
Kennett Square, PA 19348
www.sccsfa.org 

NON-PROHIBITED PERSON DECLARATION, RELEASE OF IMAGE AND LIKENESS, ASSUMPTION OF RISK, RELEASE OF LIABILITY, HOLD HARMLESS AGREEMENT, INDEMNITY AGREEMENT, and HEALTH CONDITION DECLARATION

IMPORTANT! This is a binding legal Agreement. Read it CAREFULLY before signing. By signing this Agreement, you are giving up important legal rights. 

1. Terms:
a. SCCSFA:
the Southern Chester County Sportsmen s and Farmers Association, Inc. and its officers, officials, directors, members, owners, shareholders, employees, agents, attorneys, insurers, and representatives.
b. Claims: any and all legal claims, lawsuits, causes of action, damages, expenses, injuries or costs. This includes, but is not limited to, claims for intentional acts, negligence, nuisance, noise, or any other legal claim that is cognizable in a state or federal court of law, regardless of whether related to my membership in or use of the property of SCCSFA.
c. Limitations: physical, mental, emotional or other limitations, disabilities, illnesses, injuries or conditions.

2. Agreement to Follow All Safety Rules and Directions: In consideration for me being permitted to become a Member and have use of the ranges of the Southern Chester County Sportsmen s and Farmers Association, Inc. (hereinafter SCCSFA ) or my being permitted to use SCCSFA’s property and ranges as a guest, I hereby AGREE TO FOLLOW AND COMPLY WITH the written safety rules provided to me with this Agreement, as well as all safety rules, range procedures, and directions, whether written or oral, of SCCSFA. I further agree that if I observe any safety violation by anyone (member, nonparticipant, observer, or other person), or any unsafe condition of any kind, I will IMMEDIATELY call it to SCCSFA’s attention by contacting a member of the Board. I further agree that my participation in SCCSFA may be terminated at any time by SCCSFA, in accordance with SCCSFA’s Bylaws, if I violate any safety rule, procedure or direction, in which case, any fees paid may not be refunded to me.

3. Non-Prohibited Person Declaration: By signing this Agreement, I declare, pursuant to 18 PA.C.S. 4903 False Swearing, to the best of my knowledge, information and belief that:
a. I am over eighteen (18) years of age, or if under 18, my parent(s) or guardian(s) signing this form are over eighteen (18) years of age.
b. I am not currently under indictment or information in any court of a crime that could be punished by more than one year in jail.
c. I have never been convicted in any court of a crime that could have been punished by more than one year in jail, regardless of the actual sentence imposed.
d. I am not a fugitive from justice.
e. I am not an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance.
f. I have never been adjudicated mentally defective or committed to a mental institution.
g. I have never been dishonorably discharged from the Armed Forces.
h. I am not subject to a court order restraining me from harassing, stalking, or threatening my child or an intimate partner or child of such a partner.
i. I have never been convicted in any court of a misdemeanor crime of domestic violence.
j. I have never renounced my United States citizenship.
k. I am not an alien illegally in the United States.
l. I have no unlawful, illegal, wrongful or otherwise deceitful intentions in executing this Agreement or in participating in activities at SCCSFA.

4. Release of My Image, Likeness, and Auditory Communications: I understand that my activities, including auditory communications, at SCCSFA may be photographed, videotaped and/or otherwise captured electronically by SCCSFA. I hereby grant SCCSFA all rights to use my image, likeness, and auditory communications for the purpose of advertising or otherwise promoting its purpose. I understand that use of my image, likeness, and auditory communications will be for advertising or otherwise promoting of its purposes. This use includes publishing in magazines, advertising, videos, internet websites or other, as long as it is not altered to show other than actual activities in a way that could be harmful to my character. All publications will be done tastefully and with integrity. I FORFEIT any and all rights to any CLAIMS relating to the use of my image or likeness, as described above. All photographs, videos, or other electronically captured media taken at SCCSFA remain the property of SCCSFA, and may not be used or reproduced without the express written permission of the Board of SCCSFA.

5. Assumption of Risk: I understand that my becoming a Member of SCCSFA and/or use of SCCSFA’s property as a member or guest involves numerous serious risks, including the risk of death, serious physical injury and property damage. These risks involve, but are not limited to, the risk that I may be injured by: shooting myself or being shot by someone else; being injured by ricochet bullets or fragments, splatter or splashback from targets, target frames or the range backstop; risk of firearms or ammunition exploding or bursting; risk of my falling, slipping, tripping or stumbling anywhere on SCCSFA’s property; risk of my suffering serious eye injury or blindness, hearing loss or deafness, brain damage, lead poisoning, broken bones, paralysis, sprains, strains, and other injuries resulting from use of SCCSFA’s property and the associated activities; risks of emotional and psychological injury; and other risks too varied and numerous to specify. By willingly, knowingly and voluntarily becoming a Member of SCCSFA or otherwise being permitted to use the property and ranges of SCCSFA, I hereby ASSUME ALL RISKS involved, including EVEN THOSE, WHICH MAY BE CAUSED BY THE NEGLIGENCE OR CLAIMED NEGLIGENCE OF SCCSFA.

6. Release: I further agree to RELEASE SCCSFA from LIABILITY for any and all CLAIMS, which may result from, or are in any way related to, SCCSFA or its respective property. I agree to RELEASE SCCSFA from LIABILITY for any and all CLAIMS, even if caused by the NEGLIGENCE or CLAIMED NEGLIGENCE of SCCSFA, or CLAIMS not related to my use of the SCCSFA’s property, including for noise and nuisance.

7. Indemnity Agreement: I further agree to INDEMNIFY and DEFEND SCCSFA AND HOLD SCCSFA HARMLESS from any CLAIMS, whether brought by or on behalf of me, or brought by another as a result of my actual or claimed negligence or other improper conduct.

8. Health Condition Declaration: I hereby confirm that I AM IN GOOD HEALTH, and have no Limitations that would or might make it unsafe for me to become a Member of SCCSFA and/or use the property of SCCSFA. I agree to inform SCCSFA in writing below, before becoming a Member or using its property and ranges, of any Limitations, physical or otherwise, which would or might make it unsafe or inadvisable for me to perform any particular types of activities or exercises. To the extent I develop or become aware of any such Limitations while being a Member of SCCSFA or otherwise using SCCSFA’s property and ranges, or feel that any of SCCSFA’s activities or programs are ones in which I cannot safely participate, I agree that I will immediately call this situation to the attention of the Board of SCCSFA and that I WILL NOT PERFORM ANY ACTIVITY OR PROGRAM WHICH I FEEL IS UNSAFE FOR ME TO PERFORM, OR WHICH IS BEYOND MY PHYSICAL OR MENTAL CAPABILITIES, SKILL LEVEL, or LEVEL OF TRAINING. I understand that my membership in SCCSFA and/or use of SCCSFA’s property and ranges are voluntary, and there is no requirement that I perform all, or any, of SCCSFA’s activities or programs. 

9. General Conditions:

a. To the extent that any provision of this Agreement is held to conflict with or be unenforceable under applicable law, I agree that this Agreement shall be modified by the Court to the least extent possible to render it enforceable, and shall be enforced as so modified.

b. I declare that this Agreement contain the total agreement and understanding between me and SCCSFA with regard to the subject matter hereof, that there exist no other promises, representations, terms, conditions, agreements or courses of dealing not contained herein. I further declare and agree that, in any event, this Agreement supersedes any such promises, agreements, etc. in the event they ever occurred. This Agreement may not be amended or changed except in writing signed by three (3) Members of the SCCSFA Board of Directors.

c. I declare that my membership in SCCSFA or use of SCCSFA’s property and ranges is purely voluntary, and that I am compelled neither to join SCCSFA nor to execute this Agreement.

WHEREFORE, I HEREBY ACKNOWLEDGE AND AGREE BY MY SIGNATURE BELOW that I have read and understood this Agreement, including the within (1) Terms, (2) Agreement to Follow All Safety Rules and Directions, (3) Non-Prohibited Person Declaration, (4) Release of My Image and Likeness, (5) Assumption of Risk, (6) Release, (7) Indemnity Agreement, (8) Health Condition Declaration and (9) General Conditions, and that by signing it, I expressly intend to be legally bound, as well as to bind my estate, heirs, successors and assigns. I further agree that this Agreement shall remain in force indefinitely.

Dated: November 17, 2018

First Guest Name

First Name*

Last Name*

Phone*
First Guest Date of Birth*
I certify that I am 18 years of age or older
First Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
First Guest Signature*
Second Guest Name

First Name*

Last Name*
Second Guest Date of Birth*
Second Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Third Guest Name

First Name*

Last Name*
Third Guest Date of Birth*
Third Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Fourth Guest Name

First Name*

Last Name*
Fourth Guest Date of Birth*
Fourth Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Fifth Guest Name

First Name*

Last Name*
Fifth Guest Date of Birth*
Fifth Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Sixth Guest Name

First Name*

Last Name*
Sixth Guest Date of Birth*
Sixth Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Seventh Guest Name

First Name*

Last Name*
Seventh Guest Date of Birth*
Seventh Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Eighth Guest Name

First Name*

Last Name*
Eighth Guest Date of Birth*
Eighth Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Ninth Guest Name

First Name*

Last Name*
Ninth Guest Date of Birth*
Ninth Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Tenth Guest Name

First Name*

Last Name*
Tenth Guest Date of Birth*
Tenth Guest Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
Guest Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
By signing below, you are agreeing to the foregoing and hereby release and hold SCCSFA harmless for any CLAIMS on behalf of yourself and/or the Guest, as if you are Guest:
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

My current known Limitations (including the use of any prescription or non-prescription drugs or other substances) that might affect my ability to participate fully and safely, are as follows: *

SPONSORING MEMBER INFORMATION


Name of Member *

Member No *

Phone Number *

Email Address *
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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