Women's Self-Defense Course Application

Use the following application to apply to attend our one-day course. There will be both classroom and physical instruction.

We currently don't have any courses scheduled. If you would like to complete an application, we will hold it until our next course and call you for "first in line" access.

If completing the online application, the waiver portion of the application must be signed prior to the start of class. Waivers and a notary will be available at no charge. You must have a government issued ID for proof of identification.

IMPORTANT:

All information which is recorded in this application will be used only in relation to determining the suitability and qualifications of the applicant for enrollment only, and no other purpose.

For additional information contact (706-865-6370) or email Point of contact, Megan Bennett (mbennett@whitecounty.net).

Thank you for your interest in this very informative and fun program that we are proud to be able to offer

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Applicant Name: *

Applicant Full Address: *

Applicant Mailing Address (if different):

Date of Birth:

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Primary Phone Number: *

Secondary Phone Number:

Email Address: *

Personal Information

Height: *

Approximate Weight: *

Hair Color: *

Eye Color: *

Any Physical Limitations?

(Limitations will be noted for preparations for the physical section of this course and will not exclude you from participation)

Employer:

Employer Phone:

Emergency Contact

Name: *

Phone Number: *

City/State:

How long have you lived in White County? *

Have you previously attended any other class or program hosted or sponsored by the White County Sheriff's Office? *

Yes

Please list:

Criminal History

Have you ever been arrested for any offense other than traffic? *

Yes

What was the Charge? *

When? *

Where? *

Photography and Video Release

I grant to the White County Sheriff’s Office, its representatives and employees the right to take photographs of me and my property in connection with my involvement with the Women’s Self-Defense Course. I authorize the White County Sheriff’s Office, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the White County Sheriff’s Office may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and internet content.

Ackowledgement *

By clicking here, I agree that I have read and understand the statement above

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Women's Self-Defense Course Application

Thank you for your interest in this very informative and fun program that we are proud to be able to offer

Contact Information

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