Self Defence Course - Registration Form

Programme Registration Form

Self Defence Course for women and girls 16+
Self Defence Course for women and girls 16+

Strathroy Community Centre, Omagh

Commencing Wednesday 8th October 2025

(4 week course)

7.30 - 8.30pm
Section 1

Participant Information & Permissions
Name*

ForenameSurname
Age*
Date of birth*

DayMonthYear
Date
Contact Number*
Mobile or Landline
Email (for all correspondence inc. confirmation)*

Confirmation EmailPlease confirm email address
** Information regarding programme(s) will be communicated via email. Please ensure that you check your junk / spam folder regularly encase correspondence gets diverted **
Do you have a disability that the coach needs to be aware off?*

YesNo
Please provide details regarding disability below*
Do you have any medical condition that coach should be aware off?*

YesNo
Please provide details regarding medical condition below*
Images (photographs and videos) might be taken during programme, sessions, activities etc. Images taken may be used for Council publications, promotional purposes etc. including online and shared with partner organisations involved within the delivery of the Programme.
Do you give permission to be included within photographs and/or videos associated with programme, session or activity being attended?*

YesNo
Section 2

Emergency contact information
Please provide details below for x2 emergency contacts.

Emergency contact 1 (primary) will be contacted in the first instance. Emergency contact 2 (secondary) will be contacted if the primary contact does not respond.

Emergency contact information*

	Name	Contact number
Emergency Contact 1 (Primary)
Emergency Contact 2 (Secondary)

Section 4

Participant / Programme Disclaimer
Fermanagh and Omagh District Council (FODC), partner organisations or coach associated with programme, session or activity delivery are not liable for any injury or harm that is sustained as a direct result of engagement with the programme, session or activity. Engagement is entirely at participant own risk. Participant should only engage in the programme, session or activity if fit and well to do so.
Please confirm that you have read and understood the disclaimer in Section 4*

Yes
Section 5

Data protectioon
In accordance with the Data Protection Act 2018, Fermanagh and Omagh Distrct Council has a duty to protect the information we hold on you. The personal information you provide on this form will only be used for the purpose of the programme you are attending. Information will be shared with relevant individuals, partner organisations and coaches (who may have been externally appointed to deliver the programme) to facilitate delivery.

Information will not be shared with any other organisations or individuals unless law or regulation compels such a disclosure.

For further details on how we hold your information, please visit the Privacy Section on the Council website, https://www.fermanaghomagh.com/your-council/privacy-statement

* Please select 'Yes' below (Data Protection Acknowledgement) to confirm that you have read and understood that information provided on this application form will be shared with relevant individuals, partner organisations and external coaches to enable the delivery of the programme.
Data protection acknowledgement*

Yes
Section 6

Programme Selection
Self Defence Course *
Please review information and if all required details have been included please 'submit'.
Should be Empty:

Programme Registration Form

Section 1

Section 2

Section 4

Section 5

Section 6