PCC Student Application

for weekly self-defense classes in pittsburgh

*After your 3-FREE classes, acceptance into a weekly study group requires an application and interview.

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CONTACT INFO
Name *
Name
Address *
Address
Mobile # *
Mobile #
EXPERIENCE/BACKGROUND
STANDARDS/EXPECTATIONS
REFERENCES (please list two)
NAME/CONNECTION TO YOU/PHONE#/EMAIL
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. *