INTAKE FORM

2. That I reside at:

5. That at the time of my separation from the agency listed in Paragraph 3, above, I was in good standing with said agency;

7. That prior to my separation from the agency listed in Paragraph 3, above, I was either regularly employed as a law

enforcement officer for an aggregate of 10 years or more; or, was retired from service with such agency, after completing

any applicable probationary period of such service, due to a service-connected disability, as determined by such agency;

9. That, since my separation in good standing from the agency listed in Paragraph 3, above, I have not been involved in any

action, event or condition that, if considered prior to my separation, would have prevented me from retiring in good standing;

In consideration of the acceptance of my application for and the use of Zack's Sports Inc., a New York corporation (“Zack’s Sports”) Indoor Shooting Range (the “Range”) at 2138 Route 9 Round Lake, NY 12151, and for training/qualification/courses provided by WZ Security, LLC (the “Training”), the undersigned, of, for myself, my heirs, executors, administrators and assigns, hereby waive, discharge and release in advance any and all claims for damages, death, personal injury, loss of property or property damage I may have, or that they subsequently accrue to me, or to my heirs, executors, administrators or assigns, as a result of my use of the Range and Training.

I hold harmless Zack‘s Sports and WZ Security, LLC , their directors, officers, shareholders, employees, operators, agents and range officers, without limitation, from and any and all claims or liabilities from any claim by me, or my family, estate, heirs or assigns, arising out of or connected in any way with my use of the Range and Training , even though the liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.

My participation, and use of the Range and Training, is voluntary and done at my own risk. I acknowledge and certify that I am cognizant of all the inherent dangers of the use of firearms and the Range and of the basic safety rules for activities connected with the use of the Range and Training. I understand that serious accidents occasionally occur during the use of firearms, and that persons using firearms occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof. Knowing the risks of the use of firearms, I nevertheless personally and voluntarily assume all risk of loss, damage or injury that may be sustained by me while using the Range and Training, whether foreseen or unforeseen, and to release and hold harmless all of the persons and entities mentioned above who, through negligence or carelessness or otherwise, might be liable to me or my heirs, personal representatives or assigns for damages.

I understand and agree that medical or other services rendered to me by, or at the instance of any of the persons or entities mentioned above is not an admission of liability to provide or to continue to provide any such services and is not a waiver by any of the persons or entities mentioned above of any right or rights in this Waiver and Release.

I am physically and mentally fit and capable to use and handle firearms at the Range. I understand that it is not the function of Zack‘s Sport’s or WZ Security, LLC employees, operators, agents or range officer to serve as the guardians of my safety. I also understand that if I furnish my own firearms and related equipment that I am responsible for the safety in good operating condition of those firearms and related equipment regardless of where I obtain them.

I agree to accept and abide by the safety rules and regulations of the event as established and provided to me by Zacks Sports Inc and WZ Security, LLC , their employees, operators, agents or range officer and to obey the directions of the designated officials.

I have fully informed myself of the contents of this Waiver and Release by reading it before I sign it. I am of legal age and legally competent to sign this Waiver and Release and understand the terms herein are contractual. I have signed this Waiver and Release as my own free act. In witness whereof, I have executed this Release at 2138 Route 9, Round Lake, NY

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