Registration for ProHealth Defense Lecture

If you have any questions in regards to your upcoming class, please reach out to the providing organization

that will be hosting your ProHealth Defense Lecture.

ProHealth Defense Lecture

Registration Form

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

What is your Profession? *

Massage Therapist / Service Industry

Non-Licensed Practitioner

Licensed Healthcare Practitioner

Other

If you selected Service Industry or Other, please share your service industry.

Professional Licenses # (if you do not have one, please put N/A)

State Providing License

This education lecture provides 16 credits for continued education credits. Does your license require continued education credits?

Yes, it requires continued education credits

No, it does not require continued education credits.

Name as it Should Appear on Certification

Date of Class Attending

ProHealth Defense Lecture

Acknowledgment and Agreement Form

Disclosure & Consent

Practical Self Defense Lecture

Introduction:

This document serves as a disclosure and consent form for participation in the Practical Self-Defense Education Course, tailored for both non-licensed and licensed health occupation providers, including but not limited to Massage Therapists, Orthopedics, Estheticians, and similar professions.

Course Overview:

The Practical Self-Defense Education Course is designed to equip participants with essential knowledge and skills to enhance personal safety and security in professional practice settings. The course will cover a range of self-defense techniques, situational awareness strategies, and conflict resolution tactics relevant to the healthcare environment.

Instructor Credentials:

The course will be facilitated by certified self-defense instructors with extensive experience in teaching self-defense techniques and safety protocols specifically tailored for healthcare professionals.

Course Content:

Participants can expect to learn:

Basic self-defense techniques applicable to various scenarios encountered in healthcare settings.
Strategies for de-escalating conflicts and managing potentially volatile situations.
Awareness of personal boundaries and assertiveness skills.
Practical guidance on recognizing and responding to threatening behavior.

Participant Requirements:

By signing this form, participants acknowledge that they:

1. Must attend all sessions of the Practical Self-Defense Education Course to benefit fully from the training.

2. Are responsible for their own physical and mental well-being during the course.

3. Understand that participation in practical exercises may involve physical contact and exertion.

4. Agree to follow safety instructions provided by the instructors at all times.

5. Acknowledge and agree to payment of the course at time of when payment is to be processed.

6. Acknowledge and agree that whether I am in attendance in person or Live Stream, I will be filmed and agree to being on recorded camera for any or all time, for the use and purposes of Practical Self Defense for Healthcare Occupations.

Assumption of Risk:

Participants understand and accept that the Practical Self-Defense Education Course involves physical activity and may entail some level of risk, including but not limited to minor injuries or discomfort associated with physical exertion.

Confidentiality:

Participants agree to maintain the confidentiality of any personal experiences or sensitive information shared during the course, respecting the privacy of fellow participants and instructors.

Consent for Participation:

By agreeing with check marking and signing this form you as the participant, hereby acknowledge that you have read and understood the contents of this disclosure and consent form for the Practical Self-Defense Education Course. By signing below, you voluntarily consent to participate in the course, understanding the risks involved and agreeing to abide by the guidelines outlined herein.

I acknowledge and understand this Disclose and Consent and agree to all that is outlined within it. *

I acknowledge and agree with this disclosure and consent form.

Liability Release

Practical Self Defense Lecture

Assumption of Risk:

I, the undersigned participant, understand and acknowledge that participation in the Practical Self-Defense Education Course involves physical activity and may pose certain risks, including but not limited to bodily injury, emotional distress, or property damage. I voluntarily assume all such risks and hereby release, discharge, and hold harmless the organizers, instructors, and facility hosting the course from any and all liability arising out of my participation in the course.

Release of Liability:

I hereby waive, release, and forever discharge any and all claims, demands, and causes of action against the organizers, instructors, and facility hosting the course, including their officers, employees, and agents, for any injury, loss, damage, or expense sustained by me as a result of my participation in the Practical Self-Defense Education Course.

Indemnification:

I agree to indemnify and hold harmless the organizers, instructors, and facility hosting the course from any and all claims, liabilities, damages, or expenses, including legal fees, arising from or related to my participation in the course.

Medical Authorization:

I certify that I am physically and mentally capable of participating in the Practical Self-Defense Education Course. In the event of an emergency, I authorize the course organizers to seek medical treatment on my behalf and consent to the release of medical information to appropriate healthcare professionals.

Photography and Video Release:

I grant permission for the organizers to photograph, videotape, or record my likeness and/or voice during the course. I understand that these materials may be used for promotional or educational purposes, and I waive any rights to compensation or royalties for their use.

Acknowledgment of Understanding:

I have read this Liability Release Form in its entirety and fully understand its contents. I acknowledge that by signing below, I am giving up certain legal rights and remedies, and I voluntarily agree to be bound by its terms.

I acknowledge and understand this Liability Release and agree to all that is outline within it. *

I acknowledge and agree with this liability release form.

Refund / Cancellation Policy

Practical Self Defense Lecture

We reserve the right to cancel classes up to two weeks prior to the event if there are less than four people registered. This is highly unlikely to happen, if it does we try and give as much fair warning as possible. At such time, you can choose a 100% refund, or roll their deposit over to a future training with no penalties.

A tuition rollover to a future class is allowed in the event of a healthcare emergency or injury. Two weeks’ notice is required and the fee to roll over the tuition is $75. When buying airfare, we suggest purchasing a ticket that is refundable should a schedule change occur.

No refund will be provided for cancellations made less than 7 days in advance, or in case of no-show.
A cancellation fee of 50% applies for cancellations made less than 14 days in advance.
No cancellation fee applies for cancellations made 14 or more days in advance.

I acknowledge and understand this Refund / Cancellation Policy and agree to all that is outlined within it. *

I acknowledge and agree with this refund / cancellation policy.

Signature

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Today's Date *