WEST WINDSOR TOWNSHIP POLICE DEPARTMENT

R.A.D. PROGRAM

PARENTAL CONSENT FORM

   I,                                                                                                                                               , authorize my daughter                                                                                                                                     , to attend the upcoming physical defense course offered by an instructor certified to teach the R.A.D. Self Defense Program at West Windsor Township, on ________________________.

    My signature below 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 my daughter and I are 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 that 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 signatures below hereby release Rape Aggression 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 signatures below also acknowledge 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.  TO THE BEST OF MY KNOWLEDGE, MY DAUGHTER IS NOT PREGNANT OR OTHERWISE INCAPABLE OF PERFORMING RIGOROUS PHYSICAL ACTIVITY.

SIGNATURE OF LEGAL GUARDIAN:                                                                  

TELEPHONE NUMBER FOR CONFIRMATION:                                               

DATE:                                                 

SIGNATURE OF STUDENT:                                                                                   

STUDENT'S EMAIL: _________________________________________

DATE:                                                 

STUDENT'S DATE OF BIRTH: