Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Military Veteran

Yes

Active Duty Military

Yes

Bringing a firearm *

Yes

No

Signature for below waiver *

In consideration of permission to participate in firearms’ training provided by Northern Illinois Carry LLC, NRA Certified Firearms Instructors and IL CCW Certified Instructors at the shooting range owned by Jerry Tewksbury, I do hereby release Northern Illinois Carry LLC, Jerry Tewksbury, their directors, agents, members, tournament officials, officers, employees and servants and any other contributor, sponsor or affiliate from all liability which might arise from any loss, damage, injuries or deaths which I may sustain, and any theft, unexplained disappearance or damage which may befall any of my property while in route to, during and in route from the training location. I further assume all responsibility for any guest that I may bring. I acknowledge that I am over the age of twenty one (21) and I am aware of the risks and hazards inherent upon such events, including but not limited to accidental discharge of firearms and loss of property through misplacement or theft. I voluntarily assume all such risks. I further acknowledge the right of Northern Illinois Carry NRA Certified Firearms Instructors and IL CCW Certified Instructors to terminate my participation immediately upon failure of mine or my guests to comply with all the rules, regulations and directions of the training officials. I further state that I have read the foregoing participation agreement and release and freely enter into it on behalf of myself and my distributees, heirs, next of kin, executors and administrators. By entering your first and last name you agree to this waiver.

First Name

Last Name