Student History, Information

Student Information, Emergency Contact information

Please fill out the information below prior to class beginning.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Emergency Information

Emergency Contact

Relationship

Emergency Contact Phone #

(###)

###

####

Medical Conditions

if none exist, please enter " none" in the box below

Background

Do you have formal firearms training?

Give a short description of any formal firearms training. If none, please enter 'none' below

Do you have a current concealed carry permit, or permit to carry?

Are you legally allowed to take this course in this US state

Type your Full Name

Clicking the "Submit" button below indicates your Understanding of and acceptance of the The Amendment LLC Liability Waiver. " The link for the Liability Waiver can be found below the "Submit" button

Today's Date

YYYY

The Amendment LLC, Liability Waiver

Student Information, Emergency Contact information

Important Links