Youth & Teen Self-Defense Classes Registration & Waiver
Self-defense classes begin Tuesday, January 11th and meet as follows:

Ages 6-12 meet from 6:00 PM - 7:00 PM
Ages 13-18 meet from 7:00 PM - 8:00 PM

Classes will meet for 6 consecutive weeks (Jan. 11th, 18th, 25th, Feb. 1st, 8th & 15th).

Total cost is $60 per student. Payment can be made by cash or check payable to St. Rafka Church to the church office, or by credit card here: https://goo.gl/PnKWw4 
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Student First & Last Name *
Student Age *
Does your child have any medial conditions the instructor needs to be aware of? (Allergies, Asthma, etc.)
Parent First & Last Name *
Parent Email Address *
Parent Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
PLEASE READ CAREFULLY THE BELOW WAIVER
WAIVER: The above named parent/guardian states that their child is in good physical condition and knows of no reason why he/she cannot study and participate in the self defense classes. The above named child and their parent/guardian understands the dangers and risks associated with studying self defense and agrees to defend, protect, indemnify and hold harmless St. Rafka Maronite Catholic Church against and from all claims arising from the negligence or fault of St. Rafka Maronite Catholic Church, its employees and volunteers, the Eparchy of Our Lady of Lebanon and Johnny Yaacoub which arise out of the self defense classes at St. Rafka Maronite Catholic Church, including but not limited to any personal injury, property damage, disability, death, and sickness or disease including, without limitation, any communicable disease. Additionally, the above named child and their parent/guardian agrees to protect, defend, hold harmless and fully indemnify St. Rafka Maronite Catholic Church, its employees and volunteers, the Eparchy of Our Lady of Lebanon and Johnny Yaacoub for any claim or cause of action whatsoever arising out of the above mentioned self defense classes which take place on Tuesday evenings from January 11, 2022 through February 15, 2022 that is brought against St. Rafka Maronite Catholic Church by the above named child, their parent/guardian or their family members whether such claim arises from the alleged negligence of St. Rafka Maronite Catholic Church, its employees or agents or the above named participant and their parent/guardian or Johnny Yaacoub's negligence. If any portion of this agreement is held invalid, it is agreed that the balance thereof, shall continue in full legal force and effect.  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 such treatment. *
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