Self-Defense & Emergency Preparedness Clinic General InformationName* First Last Physical or Health Conditions we should be aware of?*Do you have any physical or health conditions we should be aware of so that we can maximize your training experience?YesNoPlease provide any information that may be helpful regarding your physical or health considerationsParent/Guardian InformationName* First Last Phone Number*Preferred Email Address* Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact InformationEmergency Point of Contact*The person to call in event of an emergency First Last Your Relationship to Emergency Point of Contact*Emergency Contact Phone Number*PaymentSelect Your Option*OPTION 1: Preparation & Reality, Avoidance & Escape, Run-Hide-Fight Method, Survive the Unthinkable, and Basic First Aid. OPTION 2: Includes everything in Option 1 along with the Introduction to the Common Handgun curriculum.Pick OneOption 1Option 2Total $0.00