Parent Consent Form

Parent Consent Form

Wicen's Shooting Range, LLC, 3179 Mozart Road, Furlong, PA 18925
Parent/Guardian Name (must be person completing this form*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Minor's Name*

First NameLast Name
Minor's Age (less than 18)*
Person Responsible for Minor While at Wicen's Shooting Range (must be a current adult member of the Range)*

First NameLast Name
Person Responsible for Minor While at Wicen's Shooting Range- Telephone Number*
Please enter a valid phone number.
Parent/Guardian Consent:

I, {parentguardianName}, hereby give my consent for my child, {minorsName}, to participate in Range Activities at Wicen's Shooting Range. I understand that participation in these activities involves certain risks and hazards, including but not limited to, physical injury or harm, and I accept these risks on behalf of my child.

Release of Liability:

I agree to release, discharge, and hold harmless Wicen's Shooting Range, LLC, its employees, agents and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in activities at Wicen's Shooting Range.

Medical Information:

I hereby certify that my child is physically able to participate in activities at Wicen's Shooting Range. I authorize the Person Responsible as indicated above, Wicen's Shooting Range and its representatives to obtain medical treatment for my child in case of an emergency. I understand that I am responsible for any and all medical expenses that may be incurred on behalf of my child.

I have read and understood the terms and conditions of this permission slip, and I agree to abide by them.

Sincerely,
Date*

MonthDayYear
Date
Signature*

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