10th Annual Special Olympics Benefit Match
Saturday, May 9, 2015
Pine Bluff Gun Club
Entry Fee - $50 (includes T-shirt)
All proceeds go to Special Olympics Arkansas
Make checks payable to: Special Olympics Arkansas
 8 or More Courses of Fire 
 Lunch & Refreshments Provided 
 100 Plus Rounds of Ammo 
 Prizes to be Awarded 
 Limited to the First 85 Shooters 
Sign-in/registration will open at 7:00 a.m. on the day of the match. Shooters instruction meeting
will begin promptly at 7:50 a.m. with the match starting immediately after this meeting. There will
be a one-hour lunch break. Drinks will be available throughout the match. Please bring your own
eye and ear protection which is required. It is suggested that you bring a chair or stool of your own
since there is limited seating available. You need to be at least 16 years of age or older to
participate unless approved by the Pine Bluff Gun Club Board of Directors. Plaques will be
awarded in each division. Any problems or questions that arise will be handled and resolved at the
discretion of the Match Director and Safety Officers and will be final. You must sign a waiver to
participate. This is a lost brass match.
Name:
________________________________________________________________
Address: ________________________________________________________________
City:
____________________________ State: ________
Zip: ______________
Phone:
_________________________________________
Age:
_____________
Email Address: ____________________________________________________________
Handgun Make: ______________________ Model: ______________ Caliber: _________
Custom Defensive Pistol (CDP)
Compact Carry Pistol (CCP)


Enhanced Service Pistol (ESP)  Stock Service Pistol (SSP)
Stock Service Revolver (SSR) 
If available, check IDPA classification:
Novice

T-Shirt Size:
Marksman 
S

M
Sharpshooter

L


XL
Mail Entry to: Mike Walls
Attn: Special Olympics Benefit Match
7708 Reindeer Dr.
Pine Bluff, AR 71603

XXL
Expert


XXXL
Master



RELEASE AND WAIVER OF LIABILITY
Please help us keep Pine Bluff Gun Club (PBGC) safe. Gun accidents can result in serious
bodily injury or even death. Sometimes people with guns can create dangerous situations.
Always treat every gun like it is loaded. Assume the gun will go off by accident, so always keep
it pointed at the berm when loading or unloading (the berm is the big pile of dirt that looks like a
river levee). The berm is the only safe place to point the gun and for bullets to impact. PBGC
cannot and does not guarantee the safety of individual(s) or that individual(s) will act safely.
PBGC cannot and does not represent that firearms or other equipment, used in guest activities,
are safe or free from defects.

Always wear eye and ear protection.

Any dispute or controversy between you and PBGC, relating to this Contract, including the
validity or enforceability of any condition, or the entire Contract, shall be settled by
arbitration. Arbitrator’s decision shall be final and binding, with no appeal. BOTH PARTIES
WAIVE A TRIAL BY JURY.

PBGC means Pine Bluff Gun Club and its agents, directors, officers, employees, servants,
contactors, subcontractors, members, volunteers, instructors, safety officers, range officers,
helpers, and affiliates of any kind.

In consideration of being permitted to enter PBGC property or participate in recreational
guest activities at PBGC, I hereby release PBGC from any and all liability which might arise
from any loss, damage, injuries, or deaths which I may sustain, whether caused by the
negligence of PBGC, or otherwise, and any theft or unexplained disappearance, or damage
to my property, or the property of those accompanying me while on the premises of the
PBGC range.

I acknowledge that I am over the age of eighteen (18) and that I am aware of the risks and
hazards inherent with the activities that I undertake at PBGC, including but not limited to the
accidental discharge of firearms and voluntarily assume all such risks.

I understand that I am responsible for any damage to PBGC property or the property of
others using the range caused by me, my family member(s), or guest(s).

I acknowledge that, while participating in any competition or function at PBGC:
 I am under direct supervision of the designated range officers and agree to follow their
instructions and directives to the best of my ability.
 I will abide by all safety rules and range regulations set by the Board of Directors of
PBGC and/or the bylaws of PBGC.
 I understand that gun safety will be strictly enforced.
 I understand that my failure to comply with these rules and regulations may result in my
being asked to leave the premises and not return.
I have read and understand this release and freely enter into it on behalf of myself and my
distributes, heirs, next of kin, executors, and administrators. I understand that I am giving up any
right(s) to sue PBGC.
Printed Name ____________________________________________________
Signature _____________________________________________
Age ________
Date __________________
If younger than 18 years old, parent or legal guardian must sign below:
_____________________________________________________ Date ____________________