Prevention Action Change Registration Form
Please complete for each person attending class. If you have registered for a class before, please just note any changes to your personal information.
Email address *
How did you hear about this class?
Name *
Your answer
Age *
Your answer
Occupation/Profession
Your answer
Address: *
Your answer
Phone *
Your answer
Email
Your answer
Class Title *
Your answer
Class Date/Time *
Your answer
Cost
Your answer
LIABILITY DISCLAIMER: Instructors and facilities are not liable for personal injuries or loss of, or damage to personal property. Since this is a physical activity, injuries may occur. Each student may decline to participate in any activity that they feel may be harmful; and is also responsible to inform the instructor of any physical limitations that may prevent full participation.A doctor’s written approval is required in order to resume classes after extended illness, physical injury or accident.I have read, understand, and agree to the above stated policies. (Please type name and date) *
Your answer
Name of Participant or Parent/Legal Guardian of Minor *
Your answer
A copy of your responses will be emailed to the address you provided.
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