NRA Range Safety Officer 4-H Shooting Sports - Training Course

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					                          College of Agricultural Sciences • Cooperative Extension

   “NRA Range Safety Officer” 4-H Shooting Sports – Training Course Application
                                    Wellsboro, PA Tioga County
                            April 18 (7:00 pm) – April 20th (Noon ), 2007

      Applications due with registration fee by March 1st to Tioga County Cooperative Extension
                                 118 Main Street Wellsboro, PA 16901
                        …..Checks Payable to “PA 4-H Shooting Sports”…..

Name ___________________________________________        County ______________________
Address ___________________________________________________________________________
             Street or RR                  Town                      State Zip
Home Telephone (____) ______________ Work Telephone (____) ___________

Email Address:_____________________________

Birthdate (required for level of certification) ______________    Sex _______

NRA Member Number___________________________ (if available)

Have you attended previous 4H Shooting Sports Workshops?                Yes           No

Please list your experiences working with youth _____________________________________________

Please list your shooting experience and expertise:

Why are you interested in becoming a Pennsylvania 4-H Shooting Sports volunteer?

The workshop will be conducted at “His Thousand Hills” - Wellsboro, PA (Tioga County) from
April 18-20, 2007 Instruction will be provided by Certified NRA instructors and NRA training
counselors. Contact: Earle Robbins 570-724-9120 …

Note: Cost to the participant will be Registration Fee, includes meals, lodging & training materials.
$100.00 for 4-H educators / 4-H Leaders
$200.00 for anyone not involved in 4-H.
Checks should be made payable to “PA 4-H Shooting Sports” and included with registration.

               $100                  $200               Date __________ Check #_________ Initial _____

Community Activities
Civic/Service Clubs ___________________________________________________________________
Offices Held; ________________________________________________________________________
Honors/Recognition ___________________________________________________________________
Volunteer Service to 4-H or other Youth Organization


NRA Certified Instructor                              Yes                No
           Discipline _________________________________ Date of Certification _____________
           Discipline _________________________________ Date of Certification _____________

NRA Certified Coach    Yes         No
     Discipline _________________________________ Date of Certification _____________

NRA Training Counselor        Yes        No
     Discipline _________________________________ Date of Certification _____________

Other Certification Held ____________________________________________________________

Note: 4-H Volunteers attending this training must agree to provide 4-H Shooting
Sports training for a minimum of two years.

The program is supported with grant monies from the NRA Foundation/National
Wild Turkey Federation /Federal Cartridge Corporation /Rocky Mountain Elk
Foundation and the Pennsylvania State University.

The Pennsylvania State University is committed to the policy that all persons shall have equal access to programs, facilities, admission, and employment
without regard to personal characteristics not related to ability, performance, or qualifications as determined by University policy or by state or federal
authorities. It is the policy of the University to maintain an academic and work environment free of discrimination, including harassment. The Pennsylvania
State University prohibits discrimination and harassment against any person because of age, ancestry, color, disability or handicap, national origin, race,
religious creed, sex, sexual orientation, or veteran status. Discrimination or harassment against faculty, staff, or students will not be tolerated at The
Pennsylvania State University. Direct all inquiries regarding the nondiscrimination policy to the Affirmative Action Director, The Pennsylvania State
University, 201 Willard Building, University Park, PA 16802-2801, Tel 814-865-4700/V, 814-863-1150/TTY.