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Navigation Menu
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Home
About
Instructors & Staff
Photo Gallery
Volunteer Program
Classes
Little Warriors
Youth Program
Teens / Young Adults Program
Parents / Adults Class
For Students
Student Information
Calendar
Events / Flyers
KFA Videos
Accepted Vendors
FAQ
Therapy
SCHEDULE A FREE TRIAL
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DISNEYLAND DAY
SKI & BOAT DAY
BEACH DAY
TOURNAMENT
HALLOWEEN
CHRISTMAS
SHARK WEEK
MOVIE NIGHT
First Name
*
Last Name
*
Email Address
*
Phone
*
Please ensure that this is your best contact number as we may reach you via phone call OR text message
Can the number provided above, receive text messages?
*
Yes
No
Message/Interest
Preferred Days and Times
*
Please provide us with your preferred day and time options to schedule a phone call.
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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?
*
Yes
No
Does your child have any Diagnosis or Medical Condition?
*
Yes
No
1. If applicable, please provide the name of the diagnosis/medical condition:
*
2. Is your child currently receiving any therapies?
*
Occupational Therapy
Speech Therapy
ABA
Physical Therapy
None
Other
3. What type of school setting is your child in?
*
Mainstream Public
Mainstream with an Aide/IEP
Homeschool
Private School
Special Education
Charter School
Montessori
Preschool/Pre-k
Not in school at this time
4. Can your child follow simple directions?
*
Yes
No
5. Does your child elope when faced with a non-preferred task?
*
Elopement: Child runs away during a focused activity
Yes
No
6. Is your child easily frustrated?
*
Yes
No
7. Can your child speak in full sentences?
*
Yes
No
8. Can your child respond to basic questions?
*
Yes
No
9. As a precaution, is your child ever aggressive?
*
Yes
No
Sometimes
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?
*
Yes
No
Not sure
11. Is your child shy or social?
*
Shy
Social
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!
What is your general availability?
*
Weekdays
Weekends
Morning
Afternoon
Evening
Please provide exact day and time availability
*
Any other questions, comments or concerns?
Submit
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