Waiver Test - Citizens Defense Training LLC

Name*

Address*

Date of Birth*

Mobile Phone*

Are you a US citizen?*

If no, what is your residency status?*

Gender*

Have you ever been convicted in any court of a violent crime, domestic violence, misdemeanor, or felony?*

Yes

No

Are you under indictment or currently involved in any felony?*

Yes

No

Are you a fugitive from justice?*

Yes

No

Have you ever been adjudicated mentally deficient or incompetent?*

Yes

No

Have you ever renounced your US citizenship?*

Yes

No

Are you a member of any criminal gang or organization hostile to the US constitution?*

Yes

No

Do you have any outstanding warrants?*

Yes

No

Have you ever had a firearms identification card or concealed carry permit refused or revoked?*

Yes

No

Unfortunately, we are unable to register you for a class at this time.

Experience

Do you have any firearms training experience?*

Yes

No

What is the most recent course you have taken (please include month & year)*

Please list out the firearms you have had prior training in*

What valid (unexpired) certifications do you hold relative to firearms, martial arts, combat training, medical, or emergency services training?

Are you currently or previously LEO or Military?*

Yes

No

Have you ever been discharged, under dishonorable conditions, from the Armed Forces?*

Yes

No

Unfortunately, we are unable to register you for a class at this time.

Do you currently or have in the past worked in a security field and/or related area?*

Yes

No

If yes, please list in what capacity*

Please type your expectations for this firearms training course in the box below.*

Do you have any health concerns that may affect your ability to do physical activity or require any special accommodations?*

Yes

No

Please list any allergies, including seasonal (type N/A if none)*

Do you use any illegal substances?*

Yes

No

Unfortunately, we are unable to register you for a class at this time.

IN CASE OF EMERGENCY

Emergency Contact Name*

Relationship*

Emergency Phone

If you are or suspect yourself to be pregnant, it is strongly recommended that you refrain from any physical shooting activity due to possible lead contamination.

RELEASE AND WAIVER

In consideration of Citizens Defense Training LLC, its managers, owners, agents, contractors and associated companies and/or employees (hereinafter collectively referred to as CDT), and in consideration of my participation in events/training at any locations or ranges where events/training is being hosted by CDT (hereinafter referred to as the Range), I AGREE TO THE FOLLOWING:

I fully understand and acknowledge that (a) risks and dangers exist in my use and observation of firearms and ammunition; (b) my participation in such activities and/or use of such equipment may result in my injury or illness including, but not limited to bodily injury, strains, fractures, partial and/or total paralysis, hearing loss, eye injury, blindness, heat stroke, heart attack, lead contamination, and other ailments that could cause serious disability or death; and (c) that I assume all risk, on behalf of myself, my next of kin, and my beneficiaries, even those arising out of either unintentional or willful negligence of any other party, including CDT.*

I agree

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify CDT from any and all claims, actions, losses for bodily injury, property damage, wrongful death, loss of service or otherwise which may arise out of any use of firearms, ammunition or related equipment, or my participation in or observation of shooting or other activities on the Range.*

I agree

I agree to follow all safety rules posted or given verbally by any of CDT Staff. Specifically, I also agree to wear and provide my own eye and ear protection, at all times, while on the Range (unless CDT agrees to loan eye/ear protection for temporary use).*

I agree

I also agree not to be under the influence of alcohol or any other intoxicating substance while attending events at the Range.*

I agree

I agree that CDT, any press or private parties present, have all rights to use my photograph or image, taken while on Range property. 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. I forfeit any rights to civil action or claims in any use of my image described above. All photographs taken on the Range property remain the property of CDT and may not be used or reproduced without the express written permission of CDT management.*

I agree

I further understand that CDT is not responsible for my possessions, if they should be lost, stolen, damaged or destroyed, including any vehicle damage that may occur in driving to or parking on or near Range property.*

I agree

I HAVE READ THE FOREGOING WAIVER AND RELEASE AND I HEREBY AGREE TO ALL OF THE ABOVE CONDITIONS.*

I agree

Signature of Participant*

Email*

Password*