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Enroll your child today!

In our Heroes Circle Pediatric Healing Program, we use martial arts techniques to help children, teens and young adults cope with difficult situations associated with chronic health conditions such as cancer, sickle cell, hemophilia, heart disease, and chronic GI disease, organ transplant and other pediatric illnesses.

This non-contact, martial arts approach engages children, teens and young adults, and encourages them to use the power of our unique meditative techniques to focus their inner strength and overcome pain.

If you are a parent, caregiver or healthcare provider, please check out our program frequently asked questions (FAQs).

Our programming is free of charge and siblings are welcome.

Doctor’s Note

Please note, that we will also need a Physician Consent form signed by your child’s doctor. Usually, the hospital or doctor’s office will be happy to email or fax it to us once the doctor has completed the form. If you need us to send a blank Physician Consent Form to your doctor's office, please contact us at Programs@KidsKickingCancer.org. You can also download the form and provide it to your doctor. There will be an option for attaching a scanned copy of the form to your online registration.

Printable Registration Forms

Student Registration Form

Physician Consent Form

Online Registration

This form will take around 5-10 minutes to complete.

Step 1 of 4

Student Name(Required)

First Last

Student Primary Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

US States(Required)

Phone(Required)

Date of Birth(Required)

Gender(Required)

Ethnicity(Required)

Preferred method of communication(Required)

Phone Call

Text

Where Did You Hear About Us?(Required)

Diagnosis(Required)

Patient Physician(Required)

Primary Hospital(Required)

Known allergies or other medical conditions(Required)

Primary language spoken in the home(Required)

T-shirt size(Required)

Will you be using (MI Only) our Transportation Service?(Required)

Yes

Guardian Type(Required)

Guardian Name(Required)

First Last

Address Different from Patient(Required)

Yes

Address

Street Address Address Line 2 City ZIP / Postal Code Country

US States(Required)

Cell Phone(Required)

Other Phone

Email(Required)

Add another Parent or Guardian? (Next Page)(Required)

Yes

Secondary Guardian Type(Required)

Secondary Guardian Name(Required)

First Last

Secondary Address Different from Patient(Required)

Yes

Address

Street Address Address Line 2 City ZIP / Postal Code Country

US States(Required)

Cell Phone(Required)

Other Phone

Email(Required)

Consent(Required)

I agree to the listed terms.

1. I am the parent/legal guardian of the patient and all participating siblings listed below.

2. I understand that the Kids Kicking Cancer martial arts program is a combination of meditation, karate forms, visualizations, and breathing techniques. There is no sparring or board breaking that would pose a unique danger to children. However, in any physical activity there is always the threat of accident or injury. I understand that Kids Kicking Cancer, Inc. accepts no responsibility and is not liable for any injury to my child(ren) as a result of their participation in martial arts therapy programs. I accept full responsibility for the safety of my child(ren) while participating in Kids Kicking Cancer programs.

3. I understand that Kids Kicking Cancer accepts no responsibility for the loss, damage or theft of personal property.

4. I grant full permission for communication and sharing information between Kids Kicking Cancer staff and hospital/medical staff as it relates to my child(ren’s) care and involvement in Kids Kicking Cancer programs.

5. I grant full permission for my child(ren) to participate in Kids Kicking Cancer programs, which may include transportation, class activities, trips, outings and meetings.

6. I grant full permission to Kids Kicking Cancer, their agents, representatives and appointees to photograph and/or videotape my child(ren) and to use, publish and release for publication such photos relating to the Kids Kicking Cancer program. May include Kids Kicking Cancer website and social media. The name(s) of my child(ren) may be used in connection with the above-stated photographs with the understanding that there will be no exploitation of my child(ren) and that any photographs and/or videos will conform to good standards of taste.

7. In addition to myself, my child(ren) may be released from Kids Kicking Cancer programs to the individuals I have specified below.

8. I acknowledge that the child(ren)'s names I have listed below have full permission from their physician(s) to participate in all Kids Kicking Cancer Programs and I am accepting responsibility for their participation.

Please list the individuals, other than parent/guardian, that your child(ren) may be released to and/or serve as emergency contact for Kids Kicking Cancer Programs:

Emergency Contact Name(Required)

First Last

Relationship to child(ren)(Required)

Emergency Contact Phone(Required)

Add Another Emergency Contact?

Yes

Emergency Contact Name(Required)

First Last

Relationship to child(ren)(Required)

Emergency Contact Phone(Required)

Please list all child(ren) participating in Kids Kicking Cancer programs below. Include the patient’s name and any siblings that will be participating. By listing their names below, you are acknowledging that you have full permission from your children’s physician(s) to participate in all Kids Kicking Cancer programs and you are accepting responsibility for their participation.

Add a Sibling 1?

Yes

Participating Sibling 1 Name(Required)

First Last

Sibling 1 Date of Birth(Required)

Sibling 1 Allergies or Health Concerns?

Sibling 1 Gender(Required)

Sibling 1 T-Shirt Size(Required)

Add a Sibling 2?

Yes

Participating Sibling 2 Name(Required)

First Last

Sibling 2 Date of Birth(Required)

Sibling 2 Allergies or Health Concerns?

Sibling 2 Gender(Required)

Sibling 2 T-Shirt Size(Required)

Add a Sibling 3?

Yes

Participating Sibling 3 Name(Required)

First Last

Sibling 3 Date of Birth(Required)

Sibling 3 Allergies or Health Concerns?

Sibling 3 Gender(Required)

Sibling 3 T-Shirt Size(Required)

Add a Sibling 4?

Yes

Participating Sibling 4 Name(Required)

First Last

Sibling 4 Date of Birth(Required)

Sibling 4 Allergies or Health Concerns?

Sibling 4 Gender(Required)

Sibling 4 T-Shirt Size(Required)

Add a Sibling 5?

Yes

Participating Sibling 5 Name(Required)

First Last

Sibling 5 Date of Birth(Required)

Sibling 5 Allergies or Health Concerns?

Sibling 5 Gender(Required)

Sibling 5 T-Shirt Size(Required)

By typing your name below, you attest that all the information entered in this form is complete and accurate to the best of your ability.

If you consent to the above, please enter your name here: (Parent/Guardian)(Required)

Relationship to Patient(Required)

Relationship to Other Children(Required)

Comments / Questions

OPTIONAL: Upload signed Physician's Consent Form?

Yes

Physician's Consent Form

Max. file size: 50 MB.

Enroll your child today!

Our programming is free of charge and siblings are welcome.

Doctor’s Note

Printable Registration Forms

Online Registration

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