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SCHEDULE A FREE TRIAL
Navigation Menu
Navigation Menu
Home
About
Instructors & Staff
Photo Gallery
Karate Activities
Special Events
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
Charter Schools
Regional Center
FAQ
Therapy
SCHEDULE A FREE TRIAL
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Thank you for your interest in our program! We would be delighted to schedule you for a
FREE TRIAL CLASS!
Feel free to reach out to us with any questions or concerns you may have!
karateforall@cox.net
(714) 731-4668
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
*
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?
*
Yes
No
Does your child have any Diagnosis or Medical Condition?
*
Yes
No
If applicable, please provide the name of the diagnosis/medical condition:
*
Is your child currently receiving any therapies?
*
Occupational Therapy
Speech Therapy
ABA
Physical Therapy
None
Other
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
Can your child follow simple directions?
*
Yes
No
Does your child disengage and run around in a non-preferred group activity?
*
Yes
No
Is your child easily frustrated?
*
Yes
No
Can your child speak in full sentences?
*
Yes
No
Can your child respond to basic questions?
*
Yes
No
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.
Can your child distinguish when and when not to use Karate?
*
Yes
No
Not sure
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?
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