Chai Defense Registration Form

Chai Defense Registration Form
Date of Form Completion*

MonthDayYear
Date
Program Location*
Name (Adult/Guardian)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Adult/Guardian Date of Birth*

MonthDayYear
Date
Who will be participating in the class(please select 1 option)?*

Adult OnlyAdult and Child (List all children's names under 18 below)Child/Children Only (List all children's names 13-18 below)
What is your social media name/handle on Facebook and Instagram? Please specify the platform when entering information below:*
Child 1 Name

First NameLast Name
Date of birth

MonthDayYear
Date
Child 2 Name

First NameLast Name
Date of birth

MonthDayYear
Date
Child 3 Name

First NameLast Name
Date of birth

MonthDayYear
Date
Consent to participate

Please inform us of any and all injuries, physical limitations or special needs of all participats prior to session registration.

By participating in this activity, you are accepting the risk of an accident occurring, and agree that this activity, is suitable for you and/or your child(ren).
Signature: By providing my signature, I acknowledge that I have read, understand, and agree to the policies and procedures of the Chai Defense Release Waiver attached herein. *

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