Empowerment Self Defense Training

Name *

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Agency / School Address *

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Agency/School Phone Number *

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ESD Training location same as Agency or School? *

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Address

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Address 2

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Is the contact person the same person making the request?

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Yes

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First Choice *

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Second Choice *

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Third Choice *

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ESD Training start time *

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Please select the course that you're interested in: *

Kids Empowerment Self Defense (Ages 4-9)

Youth Self Defense and Safety (Girls 12-17)

Self Defense & Safety for Women with Disabilities & Senior Citizens

Personal Security Awareness

Women Warrior Weekend

Accomodations

Please select what you or your participants may need

ASL Interpreter

Spanish Interpreter

Tactile Interpreters

Wheelchair access

Other