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805CCW

RELEASE, WAIVER, INDEMNIFICATION,
HOLD HARMLESS, AND ASSUMPTION OF RISK AGREEMENT

     WHEREAS, In consideration of being permitted to attend a course for instruction in firearms, for the instruction in firearms, for use of premises, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, Undersigned agrees to the following:

    Undersigned agrees to indemnify, hold harmless and defend Rex A. Jones (hereafter referred to as “Instructor”), from any and all fault, liabilities, costs, expenses, claims, demands, or law suits arising out of, or connected with: Undersigned: Undersigned’s presence on or use of the range, building, land, and premises (“Premises”) and any and all acts or omissions of Undersigned.

    Undersigned furthermore waives for himself/herself and for his/her  executors, personal representatives, administrators, assignees, heirs and any next of kin; any and all rights and claims for damages, losses, demands, and any other actions or claims whatsoever, which he/she may have or which may arise against Instructor (Including but not limited to the death of Undersigned and/or any and all injuries damages or illnesses suffered by Undersigned or Undersigned’s property), which may, in any way , in any way whatsoever , arise out of, be related to or be connected with:  the course of instruction; the Premises, including any latent defect in the Premises; Undersigned’s presence on or use of said Premises;  Undersigned’s property (whether or not entrusted to Instructor); and the discharge of firearms.  Instructor shall not be liable for, and Undersigned, on behalf of himself/herself and on behalf of his/her executors, personal representatives, administrators, assignees, heirs, and next of kin, hereby expressly releases the Instructor from any and such claims and liabilities.

    Undersigned hereby expressly assumes the risk of taking part in the course for instruction in firearms and taking part in the activities on the Premises, which include, but are not limited to, instruction, instruction in the use of firearms, the discharge of firearms and the firing  of live ammunition.

Undersigned hereby acknowledges and agrees that Undersigned has read this instrument and understands its terms and is executing this instrument voluntarily.  Undersigned furthermore hereby acknowledges and agrees that he/she has read , understands at all times abide by all range rules and procedures stated by the Instructor.

Undersigned expressly agrees that this instrument is intended to be as broad and inclusive as permitted by law, and that if any provision of this instrument is held invalid or otherwise unenforceable, the enforceability of the remaining provisions shall not be impaired thereby.  No remedy, and each and every remedy shall be cumulative and said be in addition to every other remedy now or hereafter existing at law or in equity or by statue or otherwise.  The election of anyone or more remedy hereunder by the Instructor shall not constitute any waiver of Instructor’s right to pursue other available remedies.  This instrument binds Undersigned and or his/her executors, personal representatives, administrators, assignees, heirs and next of kin.

I understand it is my responsibility to consult with a physician prior to and egarding my participation in class.  I represent that I am physically fit and I have no medical, psychological or any other condition which would prevent my full participation in the firearms class.

I understand that photos and video may be taken during the class and agree that my image may be used for advertising and that extreme close up frontal facial images and names will not be published without prior approval. 

Date: January 28, 2023

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Participant Address, City, Zip Code *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Participant Address, City, Zip Code *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Participant Address, City, Zip Code *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Participant Address, City, Zip Code *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Participant Address, City, Zip Code *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Participant Address, City, Zip Code *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Participant Address, City, Zip Code *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Participant Address, City, Zip Code *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Participant Address, City, Zip Code *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Participant Address, City, Zip Code *
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Participant Address, City, Zip Code *
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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