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Villari's Self Defense & Wellness Center, LLC

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Form - On Line Application Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
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Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Agreements (required)
** Villari's Self Defense reserves the right to dismiss any student at any time for misconduct or actions that may convey a bad image of this studio. ** Villari's Self Defense is not responsible for any injuries suffered while on the premises.
Agreements (required)
** I understand that this is a contact form of Martial Arts and that I am responsible for my actions and injuries inflicted upon others or myself and will not hold Villari's Self Defense & W.C, their instructors, Cambridge Community Center, and affiliates responsible.
Selection (required)
** We are not responsible for your class attendance that is the responsibility of the student.
Date of Birth (required)

Male/Female (required)

Digital signature- By typing your name this is a legal signature. (required)

Why do you want to train? (required)


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Give us a call!
   (802)864-0844

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