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WOMEN’S SELF-DEFENSE 2018

PARTICIPANT/PARENT INFORMATION

First Name: Last Name:

Birth Date (D/M/Y): Gender: male☐ female☐ other☐

Email:

Phone Number:

Languages spoken:

Gi (Jiu Jitsu Uniform) Size: XS S M L XL

CHILDREN PARTICIPATING

Name: Birthdate: (D/M/Y)

Name: Birthdate: (D/M/Y)

ABORIGINAL DECLARATION (CHECK IF APPLICABLE)

First Nations (Status/Non-Status) ☐ Metis ☐

Inuit ☐ Other ☐:______________________

MEDICAL INFORMATION

If you have any medical conditions, please inform here:

EMERGENCY CONTACT

Name: Relationship:

Phone 1: Phone 2:

EMPLOYMENT/TRAINING INFORMATION – Since April 2017, have you went from:

No employment to part-time employment? ☐ Yes ☐ No

No employment to full-time employment? ☐ Yes ☐ No

Part-time employment to full-time employment? ☐ Yes ☐ No

Started a job training? ☐ Yes ☐ No

Completed a job training? ☐ Yes ☐ No

Started a part-time education program? ☐ Yes ☐ No

Started a full-time education program? ☐ Yes ☐ No

PHOTO RELEASE/CONSENT

I, the undersigned, do hereby consent and agree that Wii Chiiwaakanak Learning Centre, its employees,

or agents have the right to take photographs, videotape, or digital recordings of myself to use for the

purpose of publication, broadcast, promotion of future programs, or electronic/social media. I further

consent that my name and identity may be revealed therein or by descriptive text or commentary. I

waive any rights, claims, or in whatever media used. I understand that there will be no financial or other

remuneration for the photo or video.

☐ I give my consent for Wii Chiiwaakanak to take my photograph

☐ I DO NOT give my consent for Wii Chiiwaakanak to take my photograph

SIGNATURE DATE: