J_@qV

INDOOR109

EA61E GI;tl 1AHG6 *l'l-t368zqf f,4;$f-ru'*PISTOL AND RIFLE RANGE'AND GUN SHOPWO@FIELD DRIVE MACON, GA 3I2I O

lf,rru-rjrogst sTrli- s,

We * $e Eagle Gun RilEe uuehome )txr b our rrcw facility. tlVe ralue )lou as a cuttomer ad are goiq b m*eevery effort b assure tlat your visits are a safe, pleasant, rd fun experience for 1pr and your friends ardfamily. Please cornptete this information *reet d read,the SAFETY RULES m tre back. Please abfote bythese rules, they are for yanr protection.

DArE: 6, }S - 1 q

CUSTOMER NUMBER (DRIVERS LICENSE):

ITAME:

ADDRESS:

't^ - srArEAzrn lat)hcIrY: / \aCC, *'^

TELEPHONE:

SHOOTING INTERESf,S:

)fr^?soo

f)rir-

)

I certify thst L am a legal rcsident of The t nitd States of America, tlrt I have never bcen cmvictcd of a felony crimeor presently under indictment for samc, rd will faithfully cndeanor to fulffll the obligations of gpod siportsmamhip adsafety. l, tle unden$grnd ed afftllated p€rson (spOWc, family members, ersociata memberc), certify ttm t/we haveread all tE M,i.lGE SAFETY RII-ES rrd will comply:with drcm ad Sre byJauis of the EAGLE AI{ RANGE, lNC. tf at anytirne I scc actkns by other ctrstomers trit:mal be unsafe or any eq.ip]nent or structures that may be unsafe, I willarilmcdiatcly brftp theat to the fientim of the RAISE MASIER or MAi.IAGER of the Eagb Grxr Range or drty.

ln consideration of trc me$grrcd beirlg dlowed to use the facilities of the EAdf GtI{ RANGE, INC-, t}e undercig[reddocs hereby release, distharge, waive, hoH harmless, erd @\renant nd b sre EAGLE Gltl RANGE, lNC., its officers,directors, or enrployecs from any and all liability b fte undcrsigne4 the heirs, executors, administrators,successors, assigns, er{ next of kin, o-f the r.rdensagned, for any loss, danages, or injury, includiqg deatfi, to $eundersigneds pensoe or proparty, or for,any other wrsecpenm b tte undersigrred arising from, qrt of, or as a resultof, tle rce of tlr facilitles of EAGE.qt{ RANGE, INC by the undersi$red. The undcrsignd further consents to ildauthorizes all'eincrgenry medlcal treatm€nt to &e tndensigrred ai may'be deemed- approprhte under existingcircumstances at tu time.d al|y injury b tle unacrslgne4 ed b transporf tE unOerslgncd o tre nGarcst emergencymedcal facility, fuy whatever moarur may bc dperned ryproprtate unfu the circumstances. The tmdasigned furtheronsents b,tre tahng, maktsrg, or rccording of pictures, movies, videotap*, or other images of tire undersigned'slikeness o1voroe in arry mann€r incidentd to tE usa of thc fiicilities of the EAd-E g,N RANGE, md to ttre publishing,broadesting, u dsplall of srctr fikencss or voice wttflout ily dnpensation thcrsfor for t]re same.

TIME IN:

TIME OUT:

I..ATG NUMBER :

BE CHARGED TO THEDAMAGE TO RANGE EQUIPMENT WLL CUSTOMER

ffiJ"?.w/\sd.S-o q .sE

ev*.-=

\ ra\,/\J@\.\