WEST WINDSOR TOWNSHIP POLICE DEPARTMENT

R.A.D. PROGRAM

REGISTRATION/RELEASE FORM

NAME:                                                                                                                                                        

ADDRESS:                                                                                                                                                

CITY:                                                                             STATE:            ZIP:                                          

DATE OF BIRTH:                                                   PHONE: __________________________ EMAIL:______________________________

COURSE: Basic Physical Defense for Women             START DATE (IF KNOWN):                                                          

LOCATION: West Windsor Township

PRIMARY INSTRUCTOR:  _______________________________________

RELEASE FOR RAPE AGGRESSION DEFENSE SYSTEMS

PHYSICAL DEFENSE SYSTEM

    The undersigned hereby acknowledges to Rape Aggression Defense Systems, Inc., its founder, Executive Board, staff and instructor(s), as well as to the West Windsor Township Police Department, the Chief of Police and the officers of the West Windsor Police Department:

    That she is aware of the physical nature and possible risks of injury incident to taking this practical course in self defense; That she is physically fit to participate in this course, involving various physical techniques, and she realizes that self defense techniques cannot be successfully employed in every situation, and proficiency can only be achieved and is dependent upon thorough continued practice, exercising good judgement, and a person's natural abilities.

    The undersigned hereby releases Rape Agression Defense Systems, Inc., its founder, Executive Board, staff and instructor(s), as well as the West Windsor Township Police Department, the Chief of Police and the officers of the West Windsor Police Department, and agrees to hold them harmless, from any liability for injury that may be incurred as a result of participation in this course, or using the strategies within for self defense.

    The undersigned also acknowledges that Rape Aggression Defense Systems, Inc. is not responsible for the selection of trainers, training environments, training procedures or training equipment that an individual instructor may use during this program.

    I HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND I SIGN IT VOLUNTARILY.  BY SIGNING I AM ALSO INDICATING THAT TO THE BEST OF MY KNOWLEDGE I AM NOT PREGNANT OR OTHERWISE INCAPABLE OF PARTICIPATING IN RIGOROUS PHYSICAL ACTIVITY.

SIGNATURE:                                                                                                                                                    

DATE: