Firearm Safety Course Participant Declaration Emerald Step 1 of 4 25% Firearms Safety Course Participant DeclarationAll participants are required to perform all practical movements to meet the minimum training standard required. It is also important to note that QPS requires that only a "FIT & PROPER" person attends this course. The questionnaire is to be completed by all participants prior to the course. If you are unsure about any question please check with your instructor prior to the course date if you are unsure. Personal DetailsThis information is required and governed under state and federal privacy legislation.Your Name* First Last Phone*Ensure that you can be contacted if needed to discuss any section of this form.Age*Select your age18+17yrs16yrs15yrs14yrs13yrs12yrs11yrsIf you are under the age of 18. You must have a legal parent, step-parent or guardian present with you for the theory and practical session.Provide a copy of identification (Front)Drivers license, Weapons licence or other suitable ID with photo, Name, Date of birth and current residential address. s53 Weapons Act 1990. Bring this ID with you to the course. Not applicable for participants under the age of 18.Provide a copy of identification (Back)Drivers license, Weapons licence or other suitable ID with photo, Name, Date of birth and current residential address. s53 Weapons Act 1990. Bring this ID with you to the course. Not applicable for participants under the age of 18.I am enrolled to be trained for the following firearm categories:*Select your categoryA & BHCD Personal fitness - Physical abilityThis information is required and governed under state and federal privacy legislation.I have adequate hand/finger dexterity to safely and effectively manipulate a firearm. In your master hand and or non master hand.*YesNoNot sureI have adequate grip strength to control firearm during recoil. In your master hand and or non master hand.*YesNoNot sureI have adequate finger strength to operate a firearm in double-action mode. In your master hand and or non master hand.*YesNoNot sureDue to my disability I am supplying a modified firearm. In your master hand and or non master hand.*YesNoNot ApplicableApproval of the firearm by your instructor and or range officer must be done prior to the course date (must be a registered firearm accompanied with a current weapons licence holder for that category of firearm) I have sufficient eyesight to clearly focus on firearm sights or scope and visually discriminate between correct targets at distances up to 100m (corrective lenses permitted)*YesNoNot sureI am able to wear the mandatory protective eye wear whilst on the range. Safety Glasses or corrective lenses permitted (mandatory)*YesNoI am able to wear the mandatory protective ear wear whilst on the range. (mandatory) Plugs or ear muffs. You may wear personal equipment if approved by the instructor or range officer.*YesNoI am able to hear range commands whilst wearing mandatory hearing protection*YesNoNot sure Medical historyPlease indicate if you have ever required medical treatment for any of the following. This information is required and governed under state and federal privacy legislation.Serious sight impairment*YesNoFits, dizziness or blackouts*YesNoBrain injury*YesNoPsychiatric or emotional problems*YesNoAlcohol or Drug related problems*YesNoPhysical impairment*YesNoIf you have answered YES to any questions in this section. Contact your instructor as you may be required to provide a doctor’s certificate to certify the condition DOES NOT affect your ability to possess, use and discharge a firearm and fit to be assessed possessing using and discharging a firearm. Criminal historyThe obligation is upon the participant answer these questions truthfully to meet the requirements of s10B Weapons Act 1990 This information is required and governed under state and federal privacy legislation.Have you in Queensland or elsewhere been convicted of: Murder or manslaughter Armed Robbery Unlawful wounding Grievous bodily harm an offence involving drugs, weapons or violence that is prescribed under a regulation punishable by at least 7 years imprisonment. Tick the box if any of the following apply to you.Have you in the last 5 years, been convicted of, or discharged from custody on sentence after being convicted of any of the following? Offence relating to the misuse of drugs Offence involving the use or threatened use of violence Offence involving the use, carriage, discharge or possession of a weapon Tick the box if any of the following apply to you.Have you in the last 5 years been subject to a domestic violence order, other than a temporary protection order?*YesNoAre you currently subject to a temporary protection order?*YesNoAre you prevented by an order of a Queensland or another court outside of Queensland from holding a weapons licence or possessing a weapon unless the order permits such under supervision?*YesNoHave you in the last 5 years been subject to an involuntary assessment order under the Mental Health Act 2000, or similar order under the Mental Health Act 1974, or a similar order in another state?*YesNoHave you ever been refused a weapons licence or has your weapons licence been revoked in the last 5 years?*YesNoHas your weapons licence been suspended?*YesNoIf you ticked a box above or selected YES in this section. Please contact your instructor and discuss the history item before proceeding with this firearm safety course. You may also need further clarification from weapons licensing regarding your weapons license application or the supply of further documents.Section BreakDate* Date Format: DD slash MM slash YYYY Time* : HH MM AM PM Signature*I declare that the information I have given is true and correct in every detail and that I am not an excluded person under the provisions of section 53 of the Weapons Act 1990.If the instructor believes that any part of the practical training and or assessment requires “reasonable adjustment”. The adjustment request must be made in writing and submitted to IN 4 Training and written approval if any on the participants training file before any training and or assessment is to take place. The reasonable adjustment shall satisfy ASQA auditors, adherence to the Qld Weapons Act 1990, Weapons Regulations 2016 and IN 4 Training insurers.