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2008 CPPO Pistol Match Registration - page 2 / 2

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CALCASIEU PARISH PEACE OFFICERS ASSN. PISTOL MATCH REGISTRATION AND WAIVER

Competitor Information (please print legibly)

NAME ____________________________________________________________________________________

EMPLOYING AGENCY

_______________________________________________________________________

MAILING ADDRESS

_________________________________________________________________________

PRIMARY PHONE

SECONDARY PHONE

________________________________

________________________

email

__________________________________________

In case of emergency, please notify:

NAME ____________________________________________________________________________________

RELATIONSHIP _____________________________________________________________________________

PRIMARY PHONE

SECONDARY PHONE

________________________________

_________________________

Release from Liability and Assumption of Risk Agreement

In signing this release, I assert that;

  • (a)

    I am presently in good physical and mental health;

  • (b)

    I have no reason to believe that I am not in good physical and mental health;

  • (c)

    I am fully aware of and do acknowledge and assume all risk of injury inherent in my participation in the pistol match;

  • (d)

    I have read and fully understand the terms and conditions of this agreement;

  • (e)

    I hereby release the Calcasieu Parish Sheriff, Calcasieu Parish Sheriff's Office, Calcasieu Parish Regional Law Enforcement Training Academy, Calcasieu Parish Peace Officers Association, and all officers and members thereof, from any liability or responsibility for any physical and/or mental injury I may suffer during any and all activities associated with this pistol match.

Signature ______________________________________________

Date

_________________

Witness(es) ___________________________________________________________________

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