Your Name (required)Your Email (required)Phone (required)Today's Date (required):My child/teen's name: (required):Age (required):Grade:Please share with us any special needs or restrictions your child has:Further information I would like the instructors to have about my child:My child will be participating in a class or workshop given by DEFEND YOURSELF. I understand that this class includes some physical contact among students and between instructors and students. My child/teen is in good health and is capable of participating in this class or workshop. If my child/teen has any special physical needs or restrictions, I have included that information above and understand that I can also contact Defend Yourself director Lauren Taylor at email@example.com or 301-608-3708. I understand and agree to waive, release, and hold harmless Defend Yourself, Lauren Taylor, Farah Fosse and any other Defend Yourself instructors from any claims or liabilities for injuries (physical or other), including those caused by any negligent act or omission of any of those mentioned, arising out of the programs of Defend Yourself.I agree to let Defend Yourself use images of my child in its social media.I agreeI do not agreeI consent to and understand all of the above by checking this box and pressing submit below.