Oceanside, CA 92052-4858
Calendar Year 2013 Membership Application Form
Complete this application with the attached SMGC Release Liability Form, either mail to the below address or
bring it to the monthly rifle and/or pistol match with payment as appropriate. Annual Club membership expires
at the end of the month January 2014. Mail application to: SMGC, 175 Kenyatta Dr., San Diego, CA 92114
PLEASE PRINT LEGIBLE.
Name:_________________________________________________________________________
(Last)
(First)
(Mi)
(Rank)
Address:________________________________________________________________________
City:_________________________________ State:______________ Zip Code:_______________
Phone#:____________________________ is this a cell phone: yes:____ no:__________________
Date of Birth:________________________ E-mail address:________________________________
Driver’s License #_____________________ Driver’s License Expiration:_____________________
Are you a member of the Armed Forces or the Armed Forces Reserve?
Yes:____ No:_______
If you are a member of the Armed Forces (or Reserve), what is your expiration of active duty:___________
If you checked “yes” to Armed Forces affiliation, indicate branch of service:
USA or
USMC or
USN or
USAF or
National
USCG or
USAR
USMCR
USNR
USAFR
Guard
USCGR
Are you a Retired member of the Armed Forces or Armed Forces Reserve?
Yes:____
No:_____
Are you a dependent of an Armed Forces (Active, Reserve, Retired) Member?
Yes:____
No:_____
Are you a member of the NRA? Yes:___ No:____ NRA Membership #:____________________________
Are you a member of the CA Rifle & Pistol Assoc? Yes:___ No:___ CRPA Membership#:______________
___ Armed Forces(Active or Reserve) membership fee:
Fee Waived
___ Armed Forces (Retired or Military Dependent, Annual Membership Fee:
$15.00
___ Armed Forces Junior Dependents
$ 7.50
___ Non-military Regular Members
$50.00
___ Non-Military Regular Junior Members
$15.00
___ Non-military Associate Membership Annual Fee:
$60.00
___ Non-military Associate Membership Daily Fee:
$10.00
___ Non-military Associate Junior Membership Annual Fee:
$30.00
___ Non-military Associate Junior Membership Daily Fee:
$5.00
Are you a Range Safety Officer for MCB, Camp Pendleton, CA in accordance with USMC directives? Yes:__No:__
If yes to the above question, what date does your RSO certification expires? __________________________
Are you Armed Force medical personnel (i.e., Doctor, Nurse, Corpsman)?
Yes:___ No:___
If yes to the above question, is your certification valid and current?
Yes:___ No: ___
Are you certified as a San Diego County Emergency Medical Technician “1” or higher? Yes:___ No:___
If yes to the above question, what date does your certification expire? ______________________________
Page 1 of 3 pages
I understand that non-military regular membership in the Santa Margarita Gun Club (SMGC) is limited.
This is due to restrictions imposed by the SMGC By-Laws and Host Facility Regulations.
Therefore, I am applying for SMGC Associate Membership. Associate membership entitles me to no rights of a
Regular membership with the exception of shooting at matches.
As a regular non-military membership becomes available, I understand that I will be considered for regular non-military
as defined in the SMGC By-Laws, board resolutions or membership committee instructions.
CERTIFICATION
1.
I certify that the information listed above is correct.
2.
I further certify that I can legally participate in the shooting sport as defined in Federal and/or California Laws,
and I have not been convicted of a felony or misdemeanor crime which as a result of conviction precludes me from the
ownership, transfer, and use of firearms or ammunition.
3.
I further agree to obey all rules and regulations governing the use of military facilities as issued by appropriate
authorities and that failure to obey these rules and regulations may result in arrest and conviction in federal court.
4.
Any misrepresentation of facts may result in disbarment from the Santa Margarita Gun Club, Marine Corps
Base Camp Pendleton, CA for a period of up to five (5) years.
DATE:_____________________________________SIGNATURE:_______________________________________
Page 2 of 3 pages
P.O. Box 4858
Oceanside, CA 92052-4858
RELEASE FROM RESPONSIBILITY, WAIVER OF LIBALITY AND ASSUNMPTION OF RISK FOR
PARTICIPATION IN A DANGEROUS ACTIVITY
FOR AND IN CONSIDERATION OF permitting THE UNDERSIGNED to enter the MARINE CORPS BASE CAMP
PENDELETON AND SANTA MARGARITA GUN CLUB, herein referred to as the “Santa Margarita Gun Club”,
premises for the purpose of firearms use, shooting of firearms, observing the shooting of firearms, or any and all
purposes, THE UNDERSIGN, for himself/herself, his/her heirs, executors, administrators and assigns:
1.
Hereby voluntary release, discharges, waivers and relinquishes any and all actions or causes of action for
personal injury, property damage or wrongful death occurring to the undersigned arising as a result of engaging in or
being present at activities at the Santa Margarita Gun Club premises.
2.
Hereby covenants not to sue and voluntarily releases, waivers, discharge and relinquishes any action or causes
of action, aforesaid, which may hereafter arise for himself/herself and his/her heirs, executors, administrators and assigns
prosecute or present claim for personal injury, property damage or wrongful death against MCB, Camp Pendleton, CA or
the Santa Margarita Gun Club or any of it’s officers, agents, servants or employees for any of said causes of action,
whether the same shall arise by negligence of any of said persons or otherwise. IT IS THE INTENTION OF THE
UNDERSIGNED BY THIS INSTUMENT, TO EXEMPT AND RELIEVE THE SANTA MARGARITA GUN CLUB
OR ANY OF ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES, INCULDING VOLUNTEERS, FROM
LIBALITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY
NEGLIGENCE.
3.
Agree that in the event any claim for personal injury, property damage or wrongful death shall be prosecuted
against the Santa Margarita Gun Club. The undersigned shall indemnity and save harmless the same Santa Margarita
Gun Club and any of its officers, agents, servants or employees, including volunteers from any claim or causes of action
whomever or wherever made or presented for personal injuries, property damage or wrongful death.
4.
Agree that the forgoing release is intended to be as broad and inclusive as permitted by laws applicable in the
State of California and that of any portion thereof is held invalid, it is agreed that the balance shall; notwithstanding,
continue in full legal force and effect.
5.
Acknowledge that the Undersigned has been fully and completely advised of the potential for serious accident
incidental to engaging in firearm activities, including the potential for death, personal injury and property damage agree
to assume all risks of loss, damage or injury that may be sustained by the Undersigned.
6.
This agreement shall remain in effect until January 31st 2014 and cancels all previous agreements.
7.
The Undersigned has read the forgoing paragraphs and voluntary signs this agreement being fully aware of legal
consequences of signing the within instrument.
Date;________________________________
PRINT NAME________________________________________
SIGNATURE_________________________________________
Page 3 of 3 pages