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PARENTAL CONSENT FORM and WELLNESS FORM

 for MINORS


Summer camps for 2022 are full

 

 


I authorize my daughter to attend the upcoming physical defense course offered by an Instructor certified to teach the R.A.D. Self Defense Program at the Alaska Moving Arts Center.

My Signature below hereby acknowledges to Rape Aggression Defense Systems, Inc. its Founder, Executie Board, Staff and Instructor(s):

That my daughter will not participate in any aspect of the program she is uncomfortable with or considers unsafe.

That my daughter and I are aware of the physical nature and possible risks of injury incident to taking this practical course in self defense.  That she is physically fit to participate in this course, involving various physical techniques: and that she realizes that self defense techniques cannot be successfully employed in every situation, and proficiency can only be achieved and is dependent upon thorough continued practice, exercising good judgement, and a person's natural abilities.

The signatures below hereby release Rape Aggression Defense Systems, Inc., its Founder, Executive Board, Staff and Instructor(s), and agrees to hold them harmless from liabilitly for injury that may be incurred as a result of participation in this coiurse, or using the strategies within for defense.

The signatures below also acknowledge that Rape Aggression Defense System, Inc. is not responsible for the selection of trainers, training environments,Training procedures or training equipment that an individual Instrucctor may use during the program

I HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND I SIGN IT VOLUNTARILY.

Signature of Legal Guardian 

April 26, 2024

Signature of Student

April 26, 2024

 

 

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
I am registering for:
Basic Physical Defense as new student
Returning Basic Physical Defense Student
Keychain Defense
Advanced RAD Section I
Advanced RAD section II
Weapons Defense Course
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive AMAC information via email.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Confidential Medical History

Height

Weight

Date of most recent medical examination
Do you feel fine-Without Restrictions?*
No
Yes

If no, Please Describe:
Have you ever been hospitalized or treated for an injury?*
No
Yes

If yes, please describe
Have you ever been injured and not received medical attention?*
No
Yes

if yes, please describe
Do you have any current medical conditions (Please include pregnancies) for which your are currently being treated?*
No
Yes

If yes, please describe
Are you currently using any prescription drugs?*
No
Yes

If yes, please describe
Do you have any known Allergies?*
No
Yes
Difficulty Breathing?*
No
Yes
High Blood Pressure?*
No
Yes
Diabetes?*
No
Yes

If yes to any of the above, please describe

How frequently do you exercise and what type of exercise?
Are you or have you ever been involved in self-defense or Martial Arts Training?*
No
Yes

If yes, please describe

Please describe your perception of your current fitness level
The above information is complete, true and accurate to the best of my knowledge.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I am registering for:
Basic Physical Defense as new student
Returning Basic Physical Defense Student
Keychain Defense
Advanced RAD Section I
Advanced RAD section II
Weapons Defense Course
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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