Student Firearm Questionnaire v2

Date of Birth:

Name as you want it to appear on any certificates (if applicable):

Street Address:

Apt#:

City:

State:

Zip:

Firearm Memberships and Associations:

NRA Membership # (if applicable):

Other Memberships or Associations not listed:

What is your experience with firearms?

How many overall years do you have with firearms?

What type of firearms have you shot before (if applicable)?

Please list all previous training you have had (military, law enforcement, formal instruction, BSA, summer camp, hunting, safety)

What type of courses do you prefer?

What training courses are you interested in?

What teaching techniques do you learn the best from? (Check more than one but only select the best options, we all learn and have these traits. We want to know which work best for you)

Have you ever had a firearm accident? Including an accidental discharge - gun went off unexpectedly and or a negligent discharge - gun went off because you were not careful (this does not disqualify you from training)

If yes, please explain what happened.

Have you ever been hurt with a firearm? This could include being shot, slide bite (slide cutting your hand), gun exploding, wrist damage, major brass burn etc...

If yes, please explain.

Why are you interested in firearms training and what is your overall goal with firearms?

What class are you filling this questionnaire out for?

What are your goals for the course you are looking to attend?

If the course you attend requires a shooting qualification, what firearm do you plan on bringing? (please provide the make, model, caliber and any information you have on the firearm)

Do you have any medical training, certifications or licenses?

If yes, what is your background?

If asked, are you willing to provide emergency medical treatment if an accident happens?

Primary Emergency Contact Name:

Primary Emergency Contact Phone Number:

Primary Emergency Contact Relationship:

Secondary Emergency Contact Name: (If your Primary Emergency Contact is in the same course with you, make sure your secondary is not in the course)

Secondary Emergency Contact Phone Number:

Secondary Emergency Contact Relationship:

I certify all the answers are true and accurate. Type your legal name in the field below which is treated as your legal signature.