Safety & Empowerment Skills, Registration Form
Thank you for your interest Safety & Empowerment Skills! This course is open to the public for individuals who are age 13+ years old and female-identified, trans-identified, gender non-conforming, non-binary and gender expansive.

To reserve your space in our upcoming class on March 7, 2020, please register by filling out this form. Additional course information will be distributed via email the week before the course.

Please arrive on time, bring along a water bottle, and wear close-toed shoes and comfortable clothing. We look forward to working with you!
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Email *
Participant Information
First Name *
Last Name
Day Phone *
Email Address *
Address *
Street, City, Zip
How did you hear about the course? *
Age *
Required
Tell Us About Yourself
Have you taken a self-defense class before? *
Required
Do you have any martial arts background? *
Required
What do you hope to learn from this class?
Please list any health or medical considerations, special needs, or physical injuries that may affect your ability to fully participate.
Do you (or the participating student) have any health/medical or physical considerations (epilepsy, asthma, pre-existing physical injuries, etc.,) instructors should be aware of that may affect your participation in this class?  If so, please inform instructors immediately by completing the field below, or by emailing Libby Anderson at landerson@thebluebench.org. These considerations will not disqualify you from enrollment.
Safety and Empowerment Training Waiver of Liability
In consideration of the opportunity given to me to learn self-defense techniques by participation in exercises, including hand-to-hand combat exercises, and in recognition of the possible danger to which I may voluntarily subject myself in these exercises, I hereby knowingly, freely and voluntarily waive any right or cause of action, of any kind whatsoever, arising as a result of any such activity from which any liability may or could accrue to my person associated with The Blue Bench, their heirs, personal representatives or assigns. This waiver shall be binding upon my heirs, personal representatives and assigns.
Name of Participant *
Date *
Electronic Signature (of guardian if under 18 years of age) *
I, the registrant for this Safety and Empowerment Skills Training, verify the truthfulness of the information provided in this registration. I understand that checking this box constitutes a legal signature confirming that I am authorized to provide the information above and that the information provided is accurate to the best of my knowledge. *
Required
Other Considerations
Participating in a self-protection class can bring up concerns and anxiety for many participants. For this reason, we encourage all participants to enroll with a supportive friend or family member. We want to assure you that our classes are open to participants of all different physical abilities, sizes and ages. We aim to create a safe and comfortable environment where you can learn about some options you have in defending yourself against an assault.
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