Women of Color Basics Interest Form
Thank you for your interest in IMPACT's Women of Color Basics Class! This special class is open to all women of color identified folks 18+ with the intention of creating a safe space to discuss our unique experiences with safety and violence in our community while also learning and practicing boundary setting and self-defense skills. We also hope to create meaningful connections, provide opportunities for shared learning, and welcome more women of color into the Empowerment Self-Defense community.

This course will be offered free of charge (the regular price is $650), but we require a $50 deposit that will be refunded at the conclusion of the class series. If the deposit amount represents a financial hardship, please note that in your response, it will not impact whether you are invited to participate. The class is limited to 16 participants.

Our progressive teaching model requires students to attend all four class days, please only complete this form if you can attend ALL SESSIONS April 7, 14, 28, and May 5 from 10am - 4pm.

We look forward to receiving your interest form. We will review your application and be in touch within three weeks. If you have any questions or do not hear from us, please contact us at linda@impactbayarea.org

Email address *
Applicant Contact Information
Applicant's Full Name *
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Applicant's Preferred Name (optional)
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City *
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ZIP Code *
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Primary Phone Number *
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Demographic Information
Information shared will not affect our selection process. It assists us in grant reporting and increases our understanding of the populations we serve.
Date of Birth *
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Age *
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Gender *
Sexual Orientation
Ethnicity or Race *
Number of People in your Household *
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Monthly Gross Income *
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Main Source of Income *
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More Detail Information
Please tell us why you would like to be part of our first Women of Color Basics class (include any information you feel is important such as life situation, history of assault or abuse, current dangers or fears, referral by therapist or victim advocate, etc.). *
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Tell us about the current level of safety that you feel in your community. Please share what may help or hinder you from feeling safe in your day-to-day life. *
Your answer
Tell us how you might share your Empowerment Self-Defense experience with others as a leader or influencer in our community. *
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Class Dates and Deposit
Our progressive teaching model requires that you attend ALL SESSIONS April 7, 14, 28, and May 5 from 10am - 4pm. Due to limited space, all students will be asked to make a $50 deposit to hold your place. Deposits will be refunded after the final day of class.
I confirm I am able to attend class on all four dates: April 7, 14, 28, and May 5 from 10am-4pm. *
Please Select your first choice class type
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I understand that if I am selected to participate, I will be charged a $50 deposit, which will be refunded to me after the final day of class. *
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Please add your name and date below, thus confirming that the information you have provided in this form is true and correct.
Name *
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Today's Date *
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A copy of your responses will be emailed to the address you provided.
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