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INDOOR PISTOL AND RIFLE
109 WOODFIELD

RANGE'AND GUN SHOP

MACON, GA 31 2I O

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TXIVE

* $e Eade Gun RaEe uuehome )ltxr o our neu facility. tlYe ralue )rq, 6 a custqner and are gdrg b md<e
every effort b assure tlut your visits are a safe, deasanL ad fun experience for you d your friends ad
family. Please cornptete this information *reet d read $e SAFETY RULES qr tfe hck. Please abir*e by
We

these rules, they are for yon protection.

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CUSTOMER NUMBER (DRIVERS LICENSE):

MME:
ADDRESS:

cIrY:

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TELEPHONE:

SHOOTING IIWERESI'S:

I certify that L am a legal rcsident of The t nited States of America, tlrt I hane never bcen corwicted of a felony crime
or presently urder irdictment for same, ad will faithfulty cndeanor to fulffll the obligntions of gpod sportsmamlrip and
safety. l, tte umden$gned ard affillated person (spoUse, family members, ersociate memberc), certify ttm l/we have
read all tE M,i.lGE SAFETY RIX-ES rrd will conrply with $cm ad ttre by{auis of the EAGLE qI{ RANGE, lNC. lf at any
Ume I sce rctions by other clrstomers that may:be unsafe or any eq$nent or structures that may be unsafe, I will
inrmcdately brtrg ttrem to tfie attentim of the MI.IGE MASIER a MAiIAGER of the Eagb Gtsr Range or &rty.

m&ligned

facilities of trc EAgf GLN RANGE, INC-, tle unfu;i$red

co\renrtt nd E sre EAf,.E Gltl RANGE, lNC., its officers,
directors, or enrployees from any and all liability to tre undcrslgne4 tfu heirs, executors, administrators,
successors, assigns, and next of kin, oJ the undensigned, for any loss, danagies, or injury, indrrdirqg death, to tle
tndersigned's person or proparty, or for any other srseqlene b tte undersigrred arising from, o.rt of, or as a resutt
of, tle rse of ttp facilitles of EAd-E.d,!tt RANGE, INC by the tnder:X$ed. The undcrsisrd further conscnts to ad
authorizes all emeigencf'medical'tretment to &e rndensi,grred as may 'be deemed approprhte un&r existing
circumstances at fu time.of,any'injury b &e trUcrslgneO, ard b transportthe unOerslgncd O tre nGarcst emergency
medcal facility" by whatwer maars may bc deemed-ryproprirate under the circumstan-ces. The rndersi$rcd tu?ttrer
colserftsrb the taking, maklng, or rccording of pictures, movics, vidcotapG, or other images of ttre undersigned's
likeness or vo,icc in ani manni inddcntd to Urc-use of ttrc ftcilities of the EAd-E H.N RANGE, ad to the publishlng,
br@easting, or,dsgla3l of suctr lilcencss or voice wtErcut any compensatidr ttrerofior for tlu same.
ln consideration of the

beiqg alloryed,to use the

docs hereby release, distharge, waive, hoH harmless, erd

TIME

IN:

TIME otJT:
I..ATG

NUMBER:

DAMAGE TO RANGE EQUIPMENT WLL BE CHARGED TO THE CUSTOMER

Channel Name: Camera 2

Date /Time: 2014.ffi.251 17:7:32
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