Springfield Area Parent Child Center · Self-defense Class Registration Form

Contact Information

Attendee Name *

First Name

Last Name

If you are 18 years of age or older, you can skip this question. If under 18 years of age, a parent must complete this form. What is the parent's name?

First Name

Last Name

Primary Contact's Email *

Verify Email *

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Emergency Contact Name and Phone Number: *

This is required no matter your age.

Please share any accessibility needs or medically necessary information we should know about for you/your child to safely and successfully attend this course. If this does not apply to you, please type N/A. *

Photo Release *

Please check the the appropriate box below to indicate if you agree to allow SAPCC to publish photos taken of you/your child at this event and use them for marketing purposes for our programs. Please follow the "SAPCC Workforce Development & Training Center" Facebook page to view photos that we take from this learning experience.

Yes, I agree

No, I do not agree

Waiver *

By submitting this registration form, you are agreeing that you/your child can participate in this course and that you shall indemnify and hold harmless Springfield Area Parent Child Center and their educational partners against any and all legal actions which may arise from attending this course and/or using the skills learned from the course. Springfield Area Parent Child Center shall not be held liable for any injuries, legal actions, and/or loss of reputation or business opportunities that may incur as a consequence of your/your child's actions.

Yes, I agree

Payment *

$20 - if paying in advance

$0 - for those who are paying in person

Keeping in Touch *

Do you want to be added to our mailing list to receive occasional news about upcoming events and programs? We promise not to spam you!