Basic Physical Defense Registration

Instructed by Detective Jamie L. Zecman July 30 - 31, 2018 6 - 8pm Greater Midland Community Center- 2205 Jefferson Ave., Midland, MI 48640 Women Only - Grade 8 & Up

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Phone*
Email*
Emergency Contact Info.
In case of emergency please contact*
First Last
Phone*
Relationship*
Other Info.
Do you have any current medical conditions (please include pregnancies) for which you are currently being treated?*
If yes, please describe:
Are you or have you ever been involved in self-defense or Martial Arts Training?*
If yes, please describe:
Type of Registration*
Name of your Friend if using Friend Registration
Total
$0.00
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Emergency Contact Info.

Other Info.