Liability Waiver for Self Defense Class
Please complete this form to participate in the self-defense class waiver process.
Participant Information
Participant Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Class Details
Class Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Class Session
Please Select
Morning
Afternoon
Evening
Weekend
Other
Class Location
*
Class Type / Level
Beginner
Intermediate
Advanced
Mixed Level
Other
Health and Readiness
Do you have any current injuries, medical conditions, or physical limitations that may affect safe participation?
*
No
Yes
If yes, please describe the relevant condition or limitation and any safety considerations.
Are there any movements, drills, or activities you should avoid during class?
Liability Waiver and Acknowledgment
Participant Signature
*
Submit
Submit
Should be Empty: