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RELEASE FOR ADULT PARTICIPANTS 

 RAPE AGGRESSION DEFENSE SYSTEMS PHYSICAL DEFENSE COURSE

AND WELLNESS FORM

The undersigned hereby acknowledges to Rape Aggression Defense Systems, Inc., it's Founder, Executive Board, Staff and Instructor(s);

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

That should she choose to participate, is 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 she realizes that self defense techniques cannot be successfully emplyed 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 undersigned hereby releases Rape Aggression Defense Systems, Inc., its Founder, Executive Board, Staff and Instructor(s), and agrees to hold them harmless, from any liability for injury that may be incurred as a result of participation in this course, or using the strategies for defense.

The undersigned also acknowledges that Rape Aggression Defense Systems, Inc. is not responsible for the selection of trainers, training environments, training procedures or training equipment that an individual Instructor may use during this program.

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

April 19, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
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
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Confidential Medical History

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 you are currently being treated?*
No
Yes

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

If yes, please describe
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? 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.
How did you hear about RAD-Systems?
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
I am registering for:
Basic Physical Defense as a new student
Returning Student for Basic Physical Defense
Keychain Defense
Advanced RAD section I
Advanced RAD section II
Weapon Defense
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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