Broken Arrow Defense Account & Liability Waiver Form

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Broken Arrow Defense - Account Creation & Liability Waiver Form

This form must be filled out and submitted before your first class or private session with Broken Arrow Defense.

"*" indicates required fields

1Applicant Information

2Medical & Emergency

3Liability & Media Waivers

4Create Account

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone*

Date of Birth*

Are you a US citizen?*

If no, what is your residency status?*

Gender*

Height*

Weight*

Do you hold a domestic or international valid driver's license?*

Yes

Have you ever been convicted of a felony?*

Yes

Might you have any outstanding warrants?*

Yes

Have you ever been convicted of domestic violence in any U.S. jurisdictions?*

Yes

Have you ever had a firearms identification card refused or revoked?*

Yes

Unfortunately, we are unable to register you for a class at this time.

Experience

Do you have any firearms training experience?*

Yes

What is the most recent course you have taken (please include month & year)*

Please list out the firearms you have had prior training in*

What valid (unexpired) certifications do you hold relative to firearms, martial arts, combat training, medical, or emergency services training?

Are you currently or previously LEO or Military?*

Yes

If yes, will you be training with a service gun/gear or your personal gun/gear?*

Yes

Do you currently or have in the past worked in a security field and/or related area?*

Yes

If yes, please list in what capacity*

Please type your expectations for this firearms training course in the box below.*

Are you currently covered by medical insurance?*

Yes

Do you have any physical limitations that would proclude you from moving, shooting, and communicating?*

Yes

Do you have any health concerns that may affect your ability to do physical activity or require any special accommodations?*

Yes

Please list any allergies, including seasonal (type N/A if none)*

Do you use any illegal substances?*

Yes

Unfortunately, we are unable to register you for a class at this time.

IN CASE OF EMERGENCY

Emergency Contact Name*

Relationship to Applicant*

Emergency Home Phone

Emergency Cell Phone

If you are or suspect yourself to be pregnant, we strongly recommend you refrain from any physical shooting activity due to possible lead contamination.

RELEASE AND WAIVER

I, the undersigned Participant (“Participant”) hereby execute this Assumption of Risk, Waiver and Release of Liability (“Waiver”) in favor of Broken Arrow Defense Group LLC, each with an address and place of business including their respective members, directors, affiliates, employees, agents, attorneys, contractors, equipment rental providers, lessors of land or other space used for training, instructors, successors and assigns (hereinafter “BADG”). I am executing this Waiver prior to and as a condition of engaging in course(s) offered by BADG.*

I agree

BADG is providing the Course for my benefit and the benefit of others. I acknowledge that the Course, though beneficial, is not a necessity and that similar courses are offered by other entities. I am under no physical or economic compulsion from BADG to engage in the Course or to sign this Waiver.*

I agree

I acknowledge that attending and participating in the Course will increase my exposure to risk of injury arising from the Course and Course participants. I understand that this Course involves the use of live ammunition which I acknowledge is inherently dangerous. I acknowledge and understand BADG will use reasonable efforts to provide a safe and effective training environment, but acknowledge that it is impossible to eliminate all risks. I acknowledge I risk serious bodily injury and harm that includes a risk of death or dismemberment. I agree to follow all safety protocols and instructions given by BADG and the instructor. I hereby assume the risk of any and all injury arising from participation in the Course. Accordingly, I hereby assume all risks, known, unknown, and unanticipated, associated with the Course, which could result in damage or destruction of property, serious physical injury or death to myself or others (“Damages”).*

I agree

I will follow all directions given by BADG or the instructor for the duration of the Course. I acknowledge that such directions are vital for the safety of all Course participants. This includes social distancing recommendations implemented to reasonably reduce exposure to communicable diseases. Failure to follow directions from the instructor may result in my ejection from the Course, in the sole discretion of the Instructor or BADG, without refund of tuition or any monies paid by me to BADG related to the Course.*

I agree

In the event of an emergency, I hereby authorize and expressly give consent to BADG and instructors trained in the basics of first aid/CPR to administer first aid/CPR and any other medical care deemed necessary in the sole judgment of BADG and/or instructor. If the injury or illness is life threatening or in need of emergency treatment, I authorize BADG and Instructor to summon any and all professional emergency personnel to attend, transport and treat me and to issue consent for any X-ray, anesthetic, blood transfusion, medication or other medical diagnosis, treatment or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which the treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that the authorization and consent set forth in this paragraph is given in advance of any such medical treatment, but is given to provide authority and power on the part of BADG and instructor in the exercise of their best judgment upon the advice of any such medical or emergency personnel.*

I agree

I hereby acknowledge, release, covenant not to sue, and forever discharge BADG of and from any and all manner of action and actions, claims, suits, litigation, damages, judgments and demands of any kind whatsoever, whether now or in the future, at law or in equity, that results or may result from firearms or arising from the Course or any event hosted or sponsored by BADG, training or instruction by BADG, or medical care set forth in paragraph 5 above. I hereby absolve, defend, indemnify, and hold harmless BADG from any Damages I may experience arising from my participation in the Course. I expressly waive any and all rights and causes of action I may have for compensation at law and equity, including negligence, from BADG, any equipment rental providers or instructors.*

I agree

This Waiver is binding upon me, my heirs, successors, assigns, administrators, executors and estate.*

I agree

This Waiver shall be interpreted under the laws of the state of New Jersey, without regard to its conflict of laws rules.*

I agree

Any dispute arising out of this Waiver shall be settled fully and finally by binding arbitration in the state of New Jersey.*

I agree

I certify that I am over 18 years of age and a U.S. citizen. I certify that I am free of any disability or physical condition that may prohibit my participation in the Course. I certify that I am not under the influence of any prescription or non-prescription drugs or alcohol which may affect my safe participation in this Course.*

I agree

I certify that I have carefully read the entire document, fully understand it, and agree to be bound by it. I voluntarily consent and agree to this assumption of risk, waiver and release of liability.*

I agree

PHOTO & VIDEO RELEASE FORM

I do hereby grant permission to Broken Arrow Defense Group LLC to post my, my child, and/or my group’s story, photo, or other item, hereinafter referred to as “Materials,” I submit to and for Broken Arrow Defense Group LLC’s Web site, Instagram account and Facebook account. I hereby release you, your representative, employees, managers, members, officers, parent companies, subsidiaries, and directors, from all claims and demands arising out of or in connection with any use of said “Materials”, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights. I hereby release you, your representative, employees, managers, members, officers, parent companies, subsidiaries, and directors, from all claims and demands arising out of or in connection with any use of said “Materials”, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights.*

I agree

Applicant Signature*

Email*

Enter Email Confirm Email

Password*

Enter Password Confirm Password

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