Self-Defense Intake Form
If anyone in your MSA been through an experience that pertains to self-defense, would they be willing to share?

If so, they can email me directly at If they wish to stay anonymous, let them know that I [Leila Assal] will be the only one reading their testimonials and their privacy is otherwise guaranteed. We plan on publishing nameless testimonials as a part of our campaign to highlight the importance of self-defense.

It would be best if this information was sought out publicly so that the utmost privacy is maintained on such a sensitive topic.

Name of MSA Representative: *
Your answer
Phone Number (you will be contacted when we coordinate logistics for your campus) *
Your answer
Affiliated Campus of your MSA: *
Your answer
How many members are in your MSA? *
Your answer
How many members (brothers and sisters) would attend a free self-defense class offered on your campus? *
Your answer
Is your MSA comfortable with a single class of brothers and sisters?
Do you have access to large enough facilities on your campus that you can reserve for holding self-defense classes? *
First choice date for weekend self-defense classes: *
Second choice date from the above list: *
Your answer
Third choice: *
Your answer
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