CANTON POLICE DEPARTMENT

Civilian Firearms Safety Class

Saturday, Sept 30, 2017
10:00 AM 2:00 PM
Pickens County Sheriffs Gun Range
1352 Old Jones Mountain Rd
Talking Rock, GA 30175

Chief Mark J. Mitchell

Chief of Police
Citizens Police Academy Overview

Civilian Firearms Safety Class

Objective: Basic understanding of firearm safety, handling,
function, as well as laws pertaining to use.
Course cost: None!

Requirements for course:

Participants must be 21 yrs. old by the date of the class

We must receive the completed Civilian Firearms Safety Class application
prior to September 19, 2017.

In order to participate, you must furnish:

Your own pistol that is in good operating order
Minimum of 150 rounds of practice full metal jacket ammunition
Hard plastic holster that affixes to the belt or a paddle holster
Minimum of (2) 6-round magazines for semi-auto pistols

WE would highly encourage you to register quickly, as this class will fill up
quickly. Once the class has been filled we will send you an email to let you know
if you made it into this class or not.

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 CANTON POLICE DEPARTMENT
Civilian Firearms Safety Class
Date: Full Name:

Date of Birth: Social Security Number:

Home Address:

E-Mail:

Phone: Home Work Cell

Notification In Case of Emergency:

Name Address Phone #
(1)

(2)

Employment: (Company & Address)

Position or Job Title:

Have you ever been charged with a misdemeanor? If so explain:

______________________________________________________________________________

Have you ever been charged with a felony? If so explain:

______________________________________________________________________________
______________________________________________________________________________

Have you ever been convicted of a crime?

(If yes, indicated the date, charge, and disposition)

Are you, or have you ever been, placed on parole or probation? YES_______ No_________

Why do you wish to attend the Civilian Firearms Safety Class?

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 SWORN STATEMENT

I HEREBY SWEAR THAT ALL STATEMENTS MADE IN THIS

APPLICATION ARE TRUE AND COMPLETE. I ALSO UNDERSTAND
THAT ANY MISSTATEMENTS, OMISSIONS, OR FALSIFICATIONS OF
MATERIAL FACTS WILL SUBJECT ME TO DISQUALIFICATION
FROM THE CITIZENS FIREARMS CLASS PROCESS, AND COULD
RESULT IN CRIMINAL PROSECUTION UNDER GEORGIA CODE 16-
10-20.

APPLICANTS FULL LEGAL NAME (PRINT)

SIGNATURE OF APPLICANT DATE

APPLICANTS SOCIAL SECURITY NUMBER

Information contained in this Application is CONFIDENTIAL and will be retained by the Canton
Police Department.

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 CANTON POLICE DEPARTMENT
CITIZENS ACADEMY CONSENT FORM

I, , DO HEREBY AUTHORIZE A
REVIEW OF AND FULL DISCLOSURE OF ALL CRIMINAL RECORDS
CONCERNING MYSELF TO ANY DULY AUTHORIZED AGENT OF THE
CITY OF CANTON POLICE DEPARTMENT, OR TO ANY AUTHORIZED
AGENT OF A CRIMINAL JUSTICE AGENCY UPON THE REQUEST OF THE
CITY OF CANTON POLICE DEPARTMENT.

I UNDERSTAND THAT ANY INFORMATION OBTAINED BY THIS

BACKGROUND CHECK, WHICH IS DEVELOPED DIRECTLY OR
INDIRECTLY IN WHOLE OR IN PART, UPON THIS RELEASE
AUTHORIZATION, WILL BE CONSIDERED IN DETERMINING MY
SUITABILITY FOR PARTICIPATION IN THE CITIZENS POLICE
ACADEMY. I ALSO CERTIFY THAT ANY PERSON (S) OR
ORGANIZATIONS WHO MAY FURNISH SUCH INFORMATION
CONCERNING ME SHALL NOT BE HELD ACCOUNTABLE FOR GIVING
THIS INFORMATION; AND I HEREBY RELEASE SAID PERSON (S) FROM
ANY LIABILITY, WHICH MAY BE INCURRED AS A RESULT OF
FURNISHING SUCH INFORMATION.

A PHOTOCOPY OF THIS RELEASE FORM WILL BE VALID AS AN

ORIGINAL THEROF, EVEN THOUGH THE SAID PHOTOCOPY DOES NOT
CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.

Signature Date

Address

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 WAIVER OF LIABILITY
FOR PARTICIPATION IN CANTONS
FIREARMS TRAINING CLASS

I hereby affirm that I have been well advised and thoroughly informed of the inherent hazards
and policies of the City of Canton Police Department's gun training program. I know that
participation in the program is a potentially hazardous activity that includes risk of serious injury
or death. I hereby personally assume all risks associated with my voluntary participation in this
event for any harm, injury or damage whether foreseen or unforeseen, including but not limited
to gun related incidents., and, in consideration of being allowed to participate in the gun training
program, I hereby fully release, on behalf of my heirs, successors, or assigns, the City of Canton
Georgia, the Canton Police Department, and any City of Canton employees from any and all
claims for injury or damages arising from my participation in the firearms training class.

I understand and agree that neither the City of Canton, its Police Department, or its employees
may be held liable in any way for any occurrence in connection with my participation in the gun
training program that may result in injury, death or other damages to me or my family, heirs or
assigns,. I understand and agree that all entry fees are nonrefundable and nontransferable.
Further, I acknowledge and agree that the Canton Police Department, in its sole discretion, may
delay or cancel the event. I hereby personally assume all risks in connection with said event for
any harm, injury or damage that may befall me, including all risks connected therewith, whether
foreseen or unforeseen: and further to save and hold harmless said event and persons from any
claim by me or my family, estate, heirs, or assigns arising out of my participation in this event. I
further state that I am of lawful age and legally competent to sign this affirmation of release, or
that I have acquired the written consent of my parents or guardians; that I understand the terms
herein are contractual and not a mere recital; and that I have signed this document of my own
free will. It is my intention by this instrument to exempt and release the City of Canton, its Police
Department, and its employees and all event sponsors, providers, or hosts, from all liability
whatsoever for personal injury, property damage or wrongful death arising out of or in the course
of my participation in the event.

Signature Date

Address

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When you have completed this form, please return the form to the
Canton Police Department or email the application to Office Clerk,
Toni Jackson: toni.jackson@cantonga.gov

Canton Police Department

221 East Marietta St.
Canton, GA 30115
Office: 770-720-4883