RI Self-Defense Center Online Registration

Registration

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Welcome to RI Self-Defense Center! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from RI Self-Defense Center. Standard message and data rates apply. Reply STOP to opt out

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #* Receive Text Message Notifications. By opting in, you agree to receive SMS messages from RI Self-Defense Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #* Receive Text Message Notifications. By opting in, you agree to receive SMS messages from RI Self-Defense Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #* Receive Text Message Notifications. By opting in, you agree to receive SMS messages from RI Self-Defense Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #* Receive Text Message Notifications. By opting in, you agree to receive SMS messages from RI Self-Defense Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #* Receive Text Message Notifications. By opting in, you agree to receive SMS messages from RI Self-Defense Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)