Feb 2: Women's Self Defense Registration

Women's Self Defense Class
Saturday, Feb 2 from 12-2pm
$5 per person, ages 12+

* Indicates required field

Student #1 First & Last Name *

Student #1 Birth Date *

Student #2 First & Last Name *

Student #2 Birth Date *

Adult Cell *

Home Phone (if applicable) *

Mother/Guardian (if under 18) *

Father/Guardian (if under 18) *

Mother/Guardian Cell *

Father/Guardian Cell *

Email *

Please notify me *

of future self defense classes. of registration promotions.

ADDRESS:

Street *

City *

State *

Zip Code *

LIABILITY
I agree not to hold Justin Press, Ephrata Martial Arts, and/or its teachers or associates responsible for any loss, injury, accident, or liability that might occur while I or my child are participating in classes, competitions, etc. I further state that all students listed on this registration are in good health and are not restricted from any physical activities such as martial arts, etc.

Please sign that you have read and agree to the above liability statements. *

MEDIA RELEASE WAIVER
Ephrata Martial Arts is hereby granted permission to take photographs / video of any and all students to use in print or electronic publication. As student or legal guardian of student, I do understand that photos will eventually be removed from the website as pictures from the new classes / teams are put in its place. For internet safety, I understand that Ephrata Martial Arts will only use my name/my child’s name on the internet if I grant them permission (sign below). I also realize that my name/my child’s name may be mentioned in local newspapers should his or her photo be taken and used for that purpose. I am confident that photos of my student will be appropriate and of good taste. I hereby give Ephrata Martial Arts exclusive rights for all media use of my child’s image. This includes all print, non-theatrical, home video, CD-ROM, internet and any other electronic media, advertising, posters, social media and other promotional materials that may be created in the future. Ephrata Martial Arts also has the right to use and intertwine (with or without other materials) in full or portion any photographs / video footage taken as a result of participating in Ephrata Martial Arts classes and events. *This photo waiver applies to all classes, social events and public events that are associated with Ephrata Martial Arts when posting or using pictures/other media forms of the student:

Choose One *

I DO also give permission to Ephrata Martial Arts to use my name/my child's first name and last initial if needed in any internet, social mdedia, print and/or media advertising. I DO NOT give permission to Ephrata Martial Arts to use my name/my child’s name (partial or full) in any Internet, social media, print and / or media advertising. I understand that I/my child may be asked to leave a specific area of an event where photos or interviews are being taken to ensure that they are not included in media. I also understand that Ephrata Martial Arts is not responsible for other parents and/or bystanders or the general public’s ability to post students' pictures and tag my student's name on the Internet or social media sites.

Signature for Media Release Waiver (of parent/guardian if under 18) *

FINANCIAL AGREEMENT
I agree to pay the $5 class fee per person by cash or check, due at the time of the class.

Signature for Financial Agreement *

How did you hear about us / who referred you? *

Submit

Women's Self Defense ClassSaturday, Feb 2 from 12-2pm$5 per person, ages 12+

Women's Self Defense Class
Saturday, Feb 2 from 12-2pm
$5 per person, ages 12+