Chimera Registration Form

Please print out this form, fill it in, and mail it to the address on the bottom. Each participant needs to fill out a separate registration form.


Name

Age

Day Phone

Evening Phone

Address

City

State

Zip Code

Email address

Would you prefer a confirmation letter by email or regular mail?

My check for $_______is enclosed. Please contribute $_______to the scholarship fund.

Course name and dates you would like to take:____________________

____Repeating Course. My first Chimera Class was (list dates)____________.

How did you hear about this course?

Relevant Medical information:______________________________

I, the undersigned, affirm that I am in good health, and have no condition (other than listed above) which would keep me from participating in moderate physical activity. I agree to assume responsibility for any personal injury which may occur during Chimera Self-Defense classes, and that Chimera, Inc., and instructors, assistants, the Rape Crisis Center, or any sponsoring organization shall not be held responsible. I understand that Chimera is designed to help girls and women defend themselves against sexual assault. While the class is designed to be empowering and age-appropriate, the subject matter can be difficult.

Signature of Participant:

Signature of Parent or Legal Guardian (if under 18):

Please make checks payable ($30/$20 students) to the Rape Crisis Center and return with registration form to:

Chimera Self-Defense
Rape Crisis Center
2801 Coho Street, #301
Madison, WI 53713