TRIAL CLASS APPOINTMENT

TRIAL CLASS REGISTRATION

SILAT PERISAI DIRI CANBERRA
Participant Name

First NameLast Name
Participant Age*
We have noticed that this is for a person under 18 years old. Only parents/guardians are allowed to fill-in the form. If you are the parent/guardian of the child, please continue to fill in the form.
Parent Name*

First NameLast Name
Mobile Phone Number
Please enter a valid phone number.
Email*
example@example.com (appointment will be sent to this email)
Postcode
Trial Class*

One Trial Class of Women Only Self Defense and Fitness (FREE)Kids Coordination Silat activity ($30/person)General and Adult Silat training ($30/person)
Dates*

Saturdays, 18/10/2025 and 25/10/2025
Date you want to come for women-only trial class*

Saturday, 18/10/2025Saturday, 25/10/2025
For how many persons are you making this booking for?
WOMEN ONLY CLASS
Time : 12:30 PM - 01:30 PM
Room : STUDIO ONE
Place : ANU SPORT, 19 North Rd, Acton ACT 2601

Note : Please wear comfortable outfit for general exercise, including kicking.
KIDS CLASS
Time : 11:30 AM - 12:30 PM
Room : BLUE ROOM
Place : ANU SPORT, 19 North Rd, Acton ACT 2601

Note : Please wear comfortable outfit for general exercise, including kicking.
GENERAL and ADULT CLASS
Time : 12:30 PM - 01:30 PM
Room : BLUE ROOM
Place : ANU SPORT, 19 North Rd, Acton ACT 2601

Note : Please wear comfortable outfit for general exercise, including kicking.
Details:
Today*

DayMonthYear
DD/MM/YYYY
Age
How do you know about us?*

FB Page/Account of Silat Perisai Diri CanberraFB AdvertisementFB GroupIG Account of Silat Perisai Diri CanberraWhatsApp GroupReferred by a friend who already a memberPrevious member of Silat PD AustraliaOthers
Name of the person who suggest you to try?
Providing Consent for Medical Treatment:

I give my permission for a member of staff at Silat Perisai Diri to provide medical treatment if required.
Providing Consent for Photography:

I give my permission for Silat Perisai Diri taking photographs or videos to be used for publications or other media including (but not limited to) the club website, social medias, brochures, news papers, magazines, etc. Note: To ensure the privacy of the individuals (including any children), images will not be identified using full names or personal identifying information without written approval from the photographed subject, parent and/or legal guardian.
How to reach us (Kids and General)
Anjar Prayudi
M: 0451122474 (WhatsApp available)
Lead Instructor
The Martial Arts School of SILAT PERISAI DIRI CANBERRA
How to reach us (Women Only Class)
Effie
M: 0451122677 (WhatsApp available)
Instructor - Women Only Class
The Martial Arts School of SILAT PERISAI DIRI CANBERRA
How to reach us
Should be Empty:

TRIAL CLASS REGISTRATION