ADAMS COUNTY SHERRIF’S CCW CLASS STUDENT INFORMATION Name: Male __ Current address: City Phone Home: Cell: Female__ State Zip Email: IN CASE OF EMERGENCY CONTACT Name: Relationship: Phone : BREIFLY DESCRIBE LEVEL OF EXPERIENCE Check One: No experience __ Comfortable, but need more training __ Military Experience: Very comfortable, always ready to learn __ Yes __ No __ Military Firearms Training Yes __ No __ Please describe experience below; I authorize the Hosting Club and the Adams County Sheriffs Office to use my likeness in any promotional media for the benefit of the Club or Sheriff’s Office without any monetary consideration. SIGNATURE OF STUDENT: Date: Liability Release: There is an inherent danger when using firearms, by signing this form you acknowledge this danger and release the Hosting Club, all officers and members, and Adams County Sheriff’s Office Firearms Instruction Team from any and all liability. Print Name: Signature of Student: Date: ____________________ This is a two (2) day course. The fee is $75.00 per person, Make check or money order payable to JAMES W. MULLER and please put CCW class in the memo portion. Seats are limited, and your spot is not reserved until payment is received. The available 2014 class dates are listed below. Please select one: _____ August 23 & 24 2014, Hosting Club- Blue Ridge Summit _____ September 6 & & 2014, Hosting Club- Littlestown Fish & Game _____ October 4 & 5 2014, Hosting Club- Mcsherrystown Rod & Gun No refunds issued within 2 weeks of class start date Mail completed registration form with payment to: John J. Davis- 585 Funt Road, Aspers, PA. 17304 Any questions please call John J. Davis at 717 778-2075 or email: [email protected]