Self Defense Seminar Form

Date

First Name
Last Name

Address
City State Zip

Phone

Sex Please SelectMaleFemale Date of Birth

Employer Address
City State Zip

Are you in good health and with no physical problems? Please SelectYesNo

If not, please explain

Do you have any previous experience? Please SelectYesNo

If yes, please describe:

How did you first hear of American Academy of Self Defense? Please SelectYellow PagesWalk-inFlyerSpecial Ad*Referral (Please Specify)*Other (Please Specify)

*Referred by
*Other (Please Specify)

The undersigned student understands the risk of studying Martial Arts and hereby releases American Academy of Self Defense, all instructors and all other students of American Academy of Self Defense from any and all liabilities for any type of injuries and/or loss sustained while training, studying, practicing, or in the application of Martial Arts or Karate. The undersigned also states that he/she is in good physical condition and know of no reason why he/she cannot study and participate in Martial Arts. The undersigned understands that American Academy of Self Defense does not offer refunds.

In the event of an emergency, I hereby authorize any licensed medical personnel to perform any accepted medical procedure deemed necessary and agree to bear the expense of any treatment.

Signature (Please Type) Date

In case of an emergency, call: At

Your Email (required)

Cell Phone (required)

9+2=?

SUBMIT YOUR APPLICATION