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2. Women's Self Defense Training Application
4. LAST NAME*
5. FIRST NAME*
6. MIDDLE NAME*
8. ADDRESS*
10. CITY*
11. STATE*
12. ZIP*
14. DATE OF BIRTH*
15. RACE*
    -- Select One --American Indian / Alaska NativeAsianBlack / African AmericanNative Hawaiian / Pacific IslanderWhite / Caucasian
16. SEX*
    -- Select One --FemaleMale
18. SOCIAL SECURITY NUMBER*
19. DRIVER'S LICENSE NUMBER / STATE OF ISSUE*
21. EMAIL*
22. CELL PHONE NUMBER*
23. WORK PHONE NUMBER*

25. I hereby authorize the Warner Robins Police Department to receive any criminal history record information pertaining to me that may be in the files of any local or state criminal justice agency in Georgia.

    WARNER ROBINS POLICE DEPARTMENT WOMEN'S SELF DEFENSE TRAINING RELEASE AND INDEMNIFICATION

    In consideration for being allowed to participate in the Warner Robins Police Department Women's Self Defense Training and receiving benefits therefrom, I do hereby, for myself, my heirs and representatives release the City of Warner Robins Georgia, the Warner Robins Police Department and all public officials, agents, employees or servants of the City of Warner Robins, which shall be referred to collectively as the “City,” from any and all liability , claims, demands, actions and causes of action of any nature whatsoever which I may hereafter have on account of  any and all injuries, losses and or damages to me, including death, or to my property which arises out of or are related to my participation in the Women's Self Defense Training or any event or incident occurring  while I am participating in the Women's Self Defense Training program.

    For the same consideration, I agree to forever hold the City harmless for any and all liability, claims, demands, actions or causes of action that may be asserted against the City for damages, losses, injuries, and expenses to include attorney fees resulting from any participation in the Women's Self Defense Training program.

    I expressly agree that this release and indemnity is intended to be as broad and inclusive as permitted by the laws of the State of Georgia and that if any portion hereof is held invalid the balance shall continue in full force and effect.

27. ELECTRONIC SIGNATURE AGREEMENT

    By entering your name in the box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

29. ELECTRONIC SIGNATURE*
30. DATE / TIME*
    DATE / TIME

    DATE / TIME
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32. 1. Receive an email copy of this form.
33. Email address

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