Registration Form Please fill out this form before showing up for class. Contact Us Product NameClass Type(Required) One-Time Recurring Choose Your Programs (One-Time Classes)(Required) Smart Girl Self Defense Smart Girl Self Defense 1 Hour Seminar Adaptive Self-Defense: Safety Strategies for Women FIT2HIT Defense Fitness Classes Punchcard (Total of 10 Classes) Individual Self Defense and Home Safety Clearing Class Couples Self Defense and Home Safety Clearing Class Self Defense and Home Safety Clearing Refresher Course (1) 60 Minutes Private Training in Self Defense or Fitness (Per Person) (10) 60 Minute Private Training Sessions in Self Defense or Fitness Select AllChoose Your Programs (Recurring Classes)(Required) FIT2HIT Defense Fitness (16 Classes Per Month) Fight Back! Skills and Drills for Self Defense Choose Your Smart Girl Self Defense Class Date(Required) June 27th, 3 PM to 7 PM July 18th, 3 PM to 7 PM Choose Your Self Defense and Home Safety Clearing Class Date(Required) June 20th, 3 PM to 6 PM Email(Required) Name(Required) First Last Both "First Name" and "Last Name" fields are required.Phone #(Required)I authorize Smart Girl Self Defense to notify me via SMS text messages: Yes No Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name(Required) First Last Both "First Name" and "Last Name" fields are required.Emergency Contact Phone #(Required)Participant Name(Required) First Last Both "First Name" and "Last Name" fields are required.Participant Age(Required)Please enter a number greater than or equal to 1.Parent or Guardian Name (If Under 18)(Required) First Last Both "First Name" and "Last Name" fields are required.Couple / Buddy Name(Required) First Last Couple / Buddy Age(Required)Please enter a number greater than or equal to 1.Couple Buddy Parent or Guardian Name (If Under 18)(Required) First Last How did you hear about us? Returning Customer Social Media/Internet Friend/Co-Worker TV Advertisement TV KRQE Print Advertisement Do we have your permission to film or take pictures of you during the training sessions?(Required) Yes No Comments for special consideration.Participant Signature(Required)Use your mouse or finger to draw your signature.Parent or Guardian Signature (if under 18)(Required)Use your mouse or finger to draw your signature!Couple / Buddy Signature(Required)Use your mouse or finger to draw your signature!Couple / Buddy Parent or Guardian Signature (if under 18)(Required)Coupon Total Credit Card(Required) This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
