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© 2020 - 2026 Self Defense Northeast

Home
Programs
Class Schedules and Locations
Our Team
Self Defense Seminars

Intro to Kenpo Waiver Form *

Intro Kenpo Karate Class

$15

Total:$0

Choose a date *

Your Information

First Name *

Last Name *

Birthdate *

Email address *

Phone Number *

Do you have any pre-existing limitations or injuries? *

No

Yes

Please specify anything we should know about

Initials *

Waiver *

I declare that the info I’ve provided is accurate & complete.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I hereby give permission to use images and video content of myself, and minor children for marketing purposes of Bushido Martial Arts & Fitness. Children will not be indentified.

Upon submitting the form, you will be redirected to PayPal to finalize the payment.

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Intro to Karate - Child

Intro to Kenpo Waiver Form *

Intro Kenpo Karate Class

$15

Total: $0

Choose a date *

Your Information

First Name *

Last Name *

Birthdate *

Email address *

Phone Number *

Do you have any pre-existing limitations or injuries? *

No

Yes

Please specify anything we should know about

Initials *

Waiver *

I declare that the info I’ve provided is accurate & complete.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I hereby give permission to use images and video content of myself, and minor children for marketing purposes of Bushido Martial Arts & Fitness. Children will not be indentified.

Upon submitting the form, you will be redirected to PayPal to finalize the payment.

Website

Intro Krav

Intro to Krav Maga *

Intro Krav Maga Class

$15

Total:$0

Choose a date *

Your Information

First Name *

Last Name *

Birthdate *

Email address *

Phone Number *

Do you have any pre-existing limitations or injuries? *

No

Yes

Please specify anything we should know about

Initials *

Waiver *

I declare that the info I’ve provided is accurate & complete.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I hereby give permission to use images and video content of myself, and minor children for marketing purposes of Bushido Martial Arts & Fitness. Children will not be indentified.

Upon submitting the form, you will be redirected to PayPal to finalize the payment.

Name

Intro FB

Intro to Fitness Boxing *

Intro Fitness Boxing Class

$15

Total:$0

Choose a date *

Your Information

First Name *

Last Name *

Birthdate *

Email address *

Phone Number *

Do you have any pre-existing limitations or injuries? *

No

Yes

Please specify anything we should know about

Initials *

Waiver *

I declare that the info I’ve provided is accurate & complete.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I hereby give permission to use images and video content of myself, and minor children for marketing purposes of Bushido Martial Arts & Fitness. Children will not be indentified.

Upon submitting the form, you will be redirected to PayPal to finalize the payment.

Last Name

Intro Womens'

Intro Women's Self Defense *

Intro Women's Self Defense

$15

Total:$0

Choose a date *

Your Information

First Name *

Last Name *

Birthdate *

Email address *

Phone Number *

Do you have any pre-existing limitations or injuries? *

No

Yes

Please specify anything we should know about

Initials *

Waiver *

I declare that the info I’ve provided is accurate & complete.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I hereby give permission to use images and video content of myself, and minor children for marketing purposes of Bushido Martial Arts & Fitness. Children will not be indentified.

Upon submitting the form, you will be redirected to PayPal to finalize the payment.

Name