Child’s First Name *

Child’s Last Name *

Child's date of birth *

Month *

Day *

Year *

Child's Age *—

Gender *(ex: Female, Male, They, Them)

Parent/Guardian’s First Name *

Parent/Guardian’s Last Name *

Phone number *

Email Address *

Is the phone number listed above able to receive text messages? *YesNo

Does your child have any Diagnosis or Medical Condition? *YesNo

If applicable, please provide the name of the diagnosis/medical condition: *

Can your child follow simple directions? *YesNo

Does your child elope when faced with a non-preferred task? *Elopement: Child runs away during a focused activityYesNo

Is your child easily frustrated? *YesNo

Can your child speak in full sentences? *YesNo

Can your child respond to basic questions? *YesNo

As a precaution, is your child ever aggressive? *YesNoSometimes

If you selected "Yes" or "Sometimes" to question #9, please specify in what ways your child may show aggression towards themselves or others.

Can your child distinguish when and when not to use Karate? *YesNoNot sure

Is your child shy or social? *ShySocial

What goals do you have for your child in this program? *

Would your child be able to function in a large group of 15 to 20 children? *

How did you hear about us? *Please provide as much information, as we would like to share our gratitude towards those who have referred amazing families to our program!

Please provide exact day and time availability *

Any other questions, comments or concerns?

Location