PCC Self-Defense e-Course Application

for online self-defense classes in pittsburgh

Privacy Statement Sexual Abuse & Misconduct Prevention Policy

CONTACT INFO

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile #

(###)

###

####

Email Address

Age

Occupation

Sponsoring PCC Student (if any)

EXPERIENCE/BACKGROUND

1. Have you ever studied martial arts in the past?

2. If so, what did you study? And for how long?

3. How long has it been since you last practiced?

4. If you stopped practicing, why?

5. Do you have any physical or mental challenges? (old injuries, fears, etc.)

STANDARDS/EXPECTATIONS

1. Are you willing and able to make the commitment at least 2x per week to review and train on the material presented?

2. It is highly encouraged to recruit a training partner to help you learn the material. Are you able to get a training partner? (NOTE: most partner teams then split the cost of the e-Course).

3. Who would you consider to be your most influential role model? Why?

4. Have you ever been convicted of a felony?

REFERENCES (please list two)

Reference #1

NAME/CONNECTION TO YOU/PHONE#/EMAIL

Reference #2

NAME/CONNECTION TO YOU/PHONE#/EMAIL

TERMS/CERTIFICATIONS

I declare that all statements in this application and any accompanying documents are true and correct, and that any misrepresentations of false statements may be grounds for rejecting my application or, if discovered after my application has been accepted, subject me to the immediate termination of my membership as a student at the discretion of the Pittsburgh Combat Club’s without any reimbursement.

I Agree

PCC Self-Defense e-Course Selection

Choose what e-Course(s) you want to enroll in.

bone/hand-to-hand combatives e-course

baton/blunt-weapon combatives e-course

blade/edged-weapon combatives e-course

combo - 2 e-courses

combo - 3 e-courses

If you selected 2 e-courses above, which 2 courses are interested in?