2009 Junior Safety Course Registration Form

                                                                                                                     (Please print clearly)

                                                                              Date: ______________________

Name: __________________________________       D.O.B. ______________      Male / Female

Address: ______________________________________________________________________

City: _____________________________       State: ______________        Zip: ______________

Home Phone #: _____________________      Best Time To Call: ______________________

Cell Phone: __________________________              Parent’s Cell: __________________

Students email address: __________________________________________________________

Parents email address: ___________________________________________________________

NRA #: ___________________________     NYSRPA #: ____________________________

Briefly describe prior shooting experience: ___________________________________________

______________________________________________________________________________

______________________________________________________________________________

Course Name:   Junior 4 position Rifle Course_

Course Date: ________________________________ Course Fee: _      $40.00_______________

                             Parental Consent for Minor to Use the Jamestown Rifle Club Range Facilities

                                                                            Contact Person In Case Of Emergency

Name: ___________________________________ (Please Print Clearly) 

This is to certify that I, as Parent/Guardian with legal responsibility for the above named minor, do consent and agree to his/her use of the range facilities.
I hereby give my consent and permission for the above named minor to temporarily possess rifles and ammunition while shooting at the
Jamestown Rifle Club ranges.

X ___________________________________                                                     _______________

                           Parent/Guardian Signature                                                                                                                  Date