Refuse to be a Victim! Class Registration Form

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Class date: July 23, 2022 - 8:30 a.m. to 1 p.m.
Murray State College Firing Range

Cost $10.00/person - Bring weapon and ammunition plus ear and eye protection (available for purchase on site)
Payment is due upon registration. Acceptable methods of payment include check and money order and can be mailed/dropped off to: MSC Office of Advancement, One Murray Campus AD 204, Tishomingo, OK 73460. Make checks payable to Murray State College. Memo line: Refuse to be a Victim

Ladies must be age 21 or older and will learn ways to protect themselves from attackers from Tishomingo Police Chief, Shannon Smith and MSC Police Chief, Sam Holt. Must be age 18 or older to participate. Participants will receive signed certificates upon completion of the class.

Email *

Name: *

Mailing Address: *

Phone Number: *

Email Address: *

Birthday: *

YYYY

Gender: *

Male

Female

Prefer not to say

Other:

Race/Ethnicity: *

Native American or Alaska Native

White

Black or African American

Asian

Native Hawaiian or Pacific Other Islander

Other:

Please tell us what other types of workshops you would be interested in attending:

Post-Class Survey

Please expect to receive a post-class survey via email to tell us about your experience! We greatly appreciate your feedback!

Indemnity Clause

By submitting the form, I understand that I am responsible for payment of the class. I understand that I am responsible for attendance and that non-attendance does not mean a refund will be issued. I understand that I may not alter MSC facilities in any way including, but not limited to: removing furniture or equipment, painting, and/or making repairs to facilities. I hereby allow Murray State College to use my likeness in photographs and/or video for the purpose of future Continuing Education class promotion.

Indemnity clause: I will attend this class at my own risk, and indemnify Murray State College against all loss, damages, expense, and liability.

A copy of your responses will be emailed to the address you provided.

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