Self-defense Class Liability Waiver

Self-defense Class Liability Waiver
Please complete this form to participate in our self-defense class. Your information will remain confidential.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any medical conditions or injuries we should be aware of?
Have you participated in self-defense or martial arts classes before?
If yes, please briefly describe your previous experience.
Participant Signature
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Date of Signing
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: