Handgun Recreation, Training and Safety

85 North 1st Street

Stroudsburg, PA 18360

Tel (570) 424-2940

Fax (570) 424-2947

Email:

Firearms Experience & Range Safety Questionaire

Filled out on a First Shooting Visit only

Everyone who wishes to shoot in this facility, whether using their own or a Pocono Pistol Club rental firearm MUST completely fill out this form. All information supplied will be kept strictly confidential, not distributed or made available to others for any purpose, and is for the sole use by Pocono Pistol Club to properly identify the user, and to document their previous firearm experience. This is being done to best ensure the safety of all range users.

Nameemail address

AddressCityStateZip Code

Phone (home)Phone (work)

OccupationTitleEmployer

Address (work)CityStateZip Code

I would rate my previous experience with firearms as (please check as applicable):

Novice Beginner Intermediate Expert

Handgun

Rifle

Shotgun

Have you ever been adjudicated as mentally defective, been committed to a mental institution, or have a history of mental illness? yes no

Are you a user of, or addicted to, marijuana, or any depressant, stimulant or narcotic drug, or any other controlled substance? yes no

Applicant, for itself and its executors and assigns, releases the Pocono Pistol Club from any and all liability for personal injury or property damage arising out of the use of the equipment and/or facilities of Pocono Pistol Club and agree to hold free, clear and harmless for and indemnify Pocono Pistol Club from responsibility for any and all claims and demands for personal injury or property damage arising out of such use.

I agree to be held financially responsible for any knowingly willful act of destruction to the range or range equipment, beyond normal wear and tear.

SignatureDate

For You’re and Everyone's Safety Please Obey All Range Rules

Range Rules

  • Upon entering Pocono Pistol Club please check in at the counter.
  • Fill out all required paperwork prior to using range – if you have reserved a lane in advance, give yourself at least 15 minutes prior to the start of your shooting time to complete this check in process.
  • You must complete the Release, Assumptions of Risks, and Indemnity Agreement each time you
    use the range.
  • If it is your first time at Pocono Pistol Club you must take a brief safety and introductory course.
    (about 15 minutes)*
  • Use permitted firearms and ammunition ONLY. (see other side)
  • DO NOT handle guns unless you are at the firing line.
  • Eye and ear protection must be worn inside firing line at all times.
  • Always treat every gun as a loaded gun.
  • Never point a gun at something you do not want to shoot.
  • When renting a gun (minimum age 21), do not remove it from the case until you are in your lane at the firing line. When done, place back in case at firing line. Make sure gun is empty.
  • When using the gun at the firing line, ALWAYS keep the muzzle pointed down range.
  • If you have a problem with a gun at the firing line, place it down on the counter in your lane pointed down range, and come see a Rangemaster or staff in the retail area.
  • Shoot in your lane at your target only! Violators will be asked to leave.
  • Always know your background. Do not shoot above or below the bullet trap.
  • Place one target at a time on the carrier.
  • NO rapid firing.
  • Clean up your brass after you are done, however, DO NOT cross the yellow line. You may either pickup and remove your brass, or use the squeegees to push it beyond the yellow line. (toward down range)
  • Please remove all empty boxes and packaging from your booth and place it in the wastebasket.
  • Upon completion of your range time please check out at the front counter.
  • If your range time ends and you want to extend it, call the front desk by pressing the button on the intercom in your lane to see if additional time is available.
  • Obey all directives from the Rangemaster or range staff.
  • Review the Information Sheet for other rules and requirements.

I ______hereby certify that I understand the range and gun safety rules, which

(Print Range User Name)

have been explained and provided to me. I also understand that I am responsible for conducting myself in a safe, responsible manner when on the range and handling firearms.

I hereby state that I will abide by all of the rules, which have been explained, posted and/or provided to me.

______

Signature of Range UserDate

______

Signature of RSO Conducting OrientationDate