APPLICATION FOR TRAINING

Course Title: ___________________________________ Application Date: _____________________________
Course Location: ________________________________ Course Date: ________________________________
Student’s full name: _________________________________________Date of Birth: ____________________
                                               (Please print your first and last name clearly)
Mailing Address: ____________________________________________________________________________
City: _________________________________________ State: ______________ Zip Code: _______________
Phone (Home): ______________________________ Phone (cell): ___________________________________
E-Mail: ______________________________________ Occupation: __________________________________
Have you ever been arrested, other than minor traffic offense (please circle):           Yes           No
If yes, please explain circumstances ____________________________________________________________
_____________________________________________________________________________
Have you had prior firearms training?       Yes        No     if yes, please explain type of course and from whom: _________________________________________________________________________________________
How did you hear about our training: ___________________________________________________________
Why are you taking this training? ______________________________________________________________
I allow Defensive Solutions LLC to publish any photos taken of myself during this training; photos will be used solely for advertisement purposes.

__________________________________________________________________________________
(Applicant Signature & Date)
NOTE: All information is kept confidential and not sold or shared with any company or individual.
YOU MUST PROVIDE ONE OF THE FOLLOWING WITH APPLICATION
□    Copy of driver’s license/State I.D. and copy of current state concealed carry permit.
OR sign below
□    Copy of driver’s license/State I.D. and sign below. I have NEVER been convicted in any court of a crime punishable by imprisonment for a term exceeding 1 year. I am NOT a fugitive from justice. I am NOT an unlawful user of or addicted to any controlled substance. I have NEVER been adjudicated as a mental defective or have been committed to a mental institution. I am NOT an alien illegally or unlawfully in the United States or an alien admitted to the United States under a nonimmigrant visa. I have NOT been discharged from the Armed Forces under dishonorable conditions. Having been a citizen of the United States, have NEVER renounced his/her citizenship. I am NOT subject to a court order that restrains the person from harassing, stalking, or threatening an intimate partner or child of such intimate partner. I have NOT been convicted of a misdemeanor crime of domestic violence. I CAN lawfully receive, possess, ship, or transport a firearm. I am NOT a person who is under indictment or information for a crime punishable by imprisonment for a term exceeding 1 year.


Signature and date: __________________________________________________________________________________
LIABILITY RELEASE FORM
The undersigned, in consideration of the provision of services by Defensive Solutions LLC (DSLLC), Hojutsu-Ryu, their instructors/coaches, employees, representatives and facilities used for training, having perceived, appreciates and assumes the risk inherent to firearms operation, firearms instruction and training, or self-defense instruction and training including but not limited to the possibility of personal injury or property damage due to negligent or unintentional discharge, equipment malfunction or failure, ricochet, misunderstand of instruction or omission or error on the part of instructors/coaches and/or students, I do hereby agree as follows:

I hereby release DSLLC, any and all DSLLC related instructors/coaches and all other persons and organizations associated with DSLLC as well as their affiliates, agents, employees, directors, officers, and members from any and all liability and from any claim whatsoever arising out of any cause whatsoever relating in any way to the DSLLC training and I hereby agree to indemnify and hold DSLLC harmless from any and all claims, liabilities and expenses, including attorney fees relating in any way to my participation in the DSLLC training. _____________

I agree to abide by all rules for participating in DSLLC training including but not limited to: ______________
•    ALL FIREARMS ARE ALWAYS LOADED
•    DO NOT POINT A GUN AT ANYTHING YOU ARE NOT WILLING TO SHOOT, KILL OR DESTROY
•    KEEP YOUR FINGER OUT OF THE TRIGGER GUARD UNTIL YOU ARE PREPARED TO SHOOT
•    KNOW YOUR BACKSTOP AND BEYOND
•    FOLLOW ALL INSTRUCTIONAL DIRECTIONS
•    D.D.S.S. DON’T DO STUPID STUFF WHILE INPOSSESSION OF A FIREARM

I certify the following to be true: I am not a fugitive from justice and I am not under indictment nor have I been convicted of any felony or offense involving possession, use of or trafficking in any drug of abuse. I am not drug or alcohol dependent, I am not under the influence of any intoxicants, I am not under adjudication of mental incompetence, nor have I been convicted of domestic violence. Initial:______________ IF AT ANY POINT DURING THE TRAINING IT IS DISCOVERED YOU HAVE A CRIMINAL RECORD OR PENDING PROSECUTION, OR YOU DO NOT FOLLOW THE PUBLISHED SAFETY RULES; YOU WILL BE REMOVED FROM THE COURSE WITH NO REFUND!

If any DSLLC employee or any person present at DSLLC training provides transportation in connection with or related to DSLLC training, I agree that such transportation is provided solely as an accommodation and convenience to me and that such transportation is not part of DSLLC training and that DSLLC has no responsibility or liability concerning the provision of such transportation.

These general safety rules will be strictly enforced throughout the duration of this class. If at any time any one of these rules, but not limited to them, are violated and you have been asked more than one time to correct your actions, you may be excused from the course at the instructor’s discretion without a refund.


Agreed to by: (signature) ___________________________________________Date: __________________________

Print Name: ________________________________________________Phone Number: _______________________

Email address: ___________________________________________________________________________________

NOTE: All information is kept confidential and not sold or shared with any company or individual.

THANK YOU FOR KEEPING OUR TRAINING SAFE AND ENJOYABLE