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Child’s First Name *

Child’s Last Name *

Child's date of birth *

Month *

Day *

Year *

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

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

4. Can your child follow simple directions? *YesNo

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

6. Is your child easily frustrated? *YesNo

7. Can your child speak in full sentences? *YesNo

8. Can your child respond to basic questions? *YesNo

9. 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.

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

11. 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?

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