* 1. Full Name

* 2. E-mail Address

* 3. Personal Cell Number

* 4. Profession & Job Role

* 5. Please tell us if you have any physical injury(ies) that may prevent you from actively participating in this type of training, e.g. knee, ankle, wrist, spine, fractures, etc.

* 6. Have you ever been physically assaulted, or threatened of an assault?

* 7. Have you ever participated in a self-defense program of any nature prior to registering for this training?

* 8. How did you hear about this training?

* 9. I understand that the Self Defense Program (S.D.P.) is an introductory program which is covered over a period of two days (10 hours) and certificate is issued to only those participants that fulfill the entire time commitment. S.D.P. costs Rs. 12,000 (non-refundable) per person, due no later than the date communicated to me by the training firm, and does not include any additional equipment/gear. Groups of 3 or more can avail a 10% discount.

* 10. I will not hold AfterShock-CEM or its instructors responsible for any injuries sustained during this training and will abide by any/all pre session safety instructions to minimize chances of injuries.

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