Chimera Registration Form

Please print out this form, fill it in, and mail it to the address on the bottom.


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