Register for Women-only Home Defense Course We are looking forward to having you join us for our upcoming Women-only Home Defense program. First, we'd like to get some essential information. DateName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Cell*Date of Birth* Date Format: MM slash DD slash YYYY Under 18? Please email or call 978-226-8675 to discussTuition Tuition for the course is $250.00 / person. Groups If you would like to register to attend this class together with another of our Basic Protection course graduates, you’ll each receive a $15 discount on tuition. If you wish to attend together, please indicate Group attendees below and enter in the email addresses of those who are coming with you. Then fill out payment information below for the total number of members of your group. After you submit payment, the group members will receive a link to this page to fill out their information and sign waivers. Group attendeesYesNoTotal attendees*234Attendee 2 email address* Attendee 3 email address* Attendee 4 email address* Special needsWhat special needs should we be aware of? (Disability/Dairy/nut/latex allergy, or NONE) We will do our best to accommodate special physical or dietary needs. We will be providing light snacks and an allergy-friendly Dutch Oven hot lunch.Refunds-READ THIS-It's really important We'll gladly refund your fees if we cancel the class. Otherwise, because we have to pay our range rental and instructors in advance, we cannot allow rescheduling or refunds. We do this as a labor of love to help women and cancellations prevent us from doing so. Certification I certify that: * I am not under the influence of any prescription or other drug/substance that may impair my ability in any way during the course * I can legally handle firearms AND I am a US citizen or lawful permanent resident (green card holder), refugee, or have been granted asylum * I have no criminal convictions, am not currently under indictment or prosecution for any offense; nor am I wanted for questioning or arrest by any law enforcement or government agency * I will follow proper safety procedures (especially if I am pregnant) in the handling, firing, and cleaning of firearms * I understand that Adventure Protection reserves the right to refuse instruction and expel any student that creates an unsafe situation for any of the instructors or participants Registration Fee* Price: $250.00 Registration Fee* Price: $470.00 Registration Fee* Price: $705.00 Coupon - optional Registration Fee* Price: $940.00 Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Release, Waiver, Indemnification, Hold Harmless, and Assumption of Risk Agreement WHEREAS, in return for instruction in firearms, use of premises, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Undersigned agrees to the following: The Undersigned grants Adventure Protection, Inc. and its assigns, a non-exclusive, royalty-free license to use images of the Undersigned obtained during the class. This license gives "Adventure Protection" rights to use the images for promotional purposes such as but not limited to brochures, flyers, posters, and the posting on "Adventure Protection's" website or social media accounts. The Undersigned agrees to indemnify, hold harmless and defend Curtis Bingham, Adventure Protection, the Premise owner, and any of its employees, volunteers, instructors, officers, (hereinafter collectively referred to as Adventure Protection) from any and all fault, liabilities, costs, expenses, claims, demands or lawsuits arising out of, related to, or connected with: the discharge of firearms; the course of instruction; the Undersigned’s participation in the course of instruction, the Undersigned’s presence on or use of the range, buildings, land and premises (“Premises”); and any and all acts or omissions of the Undersigned. And should any such claim, demand or lawsuit arise or be asserted in any way or form whatsoever related thereto, whether arising under the laws of the United States or of any State, or under any theory of law or equity, the Undersigned will indemnify, hold harmless and defend Adventure Protection, from any and all costs, expenses or liability including, but not limited to, the cost of any settlement or judgment made or rendered against Adventure Protection, whether individually, jointly, or in solido with the Undersigned, together with all costs of court and other costs or expenses incurred in connection with any such claim, demand or lawsuit, including attorney’s fees. The Undersigned furthermore waives for herself and her executors, administrators, assignees, heirs and next of kin, any and all rights and claims for damages, losses, demands and any other actions whatsoever, which she may have or which may arise against Adventure Protection, (including, but not limited to any and all injuries, damages or illnesses suffered by the Undersigned or Undersigned’s property), which may, in any way whatsoever, arise out of, be related to, or be connected with: the course of instruction; the Premises, including any latent defect in the Premises; the Undersigned’s presence on or use of said Premises; Undersigned's property (whether or not entrusted to Adventure Protection); and, the discharge of firearms. Adventure Protection shall not be liable for, and the Undersigned, on behalf of herself and her executors, administrators, assignees, heirs and next of kin, hereby expressly releases Adventure Protection, the Premise owner, or the NRA from any and all such claims. The Undersigned hereby expressly assumes the risk of entering the Premises and of taking part in activities on the Premises which include, but are not limited to, instruction in the use of firearms, the discharge of firearms and the firing of live ammunition. The Undersigned furthermore hereby acknowledges and agrees that she has read, understands and will at all times abide by all Adventure Protection safety, range rules, procedures, and any other rules or procedures stated by the instructor. The Undersigned expressly agrees that this instrument is intended to be as broad and inclusive as permitted by law, and that if any provisions of this instrument is held invalid or otherwise unenforceable, the enforceability of the remaining provisions shall not be impaired thereby. This instrument binds the Undersigned and his/her executors, administrators, assignees, heirs and next of kin. Signing this form is voluntary. However, registration acceptance is dependent on signature. Signature*Please use your mouse (or finger if on a mobile device) to sign the form. Try to color inside the lines just this once! This iframe contains the logic required to handle Ajax powered Gravity Forms.