Application for Adult Belt Testing ___________________ ____________ Student Name Date ________________ _______________ _____ Current Belt

Rank: Belt Testing for: Size:

I have received all stripes required for Belt Testing. I will be in the proper uniform for Belt Testing. I am mentally and physically prepared to demonstrate my forms, techniques, creeds, basics at a level worthy of promotion to the next belt. I WILL, on and off the mat, demonstrate Black Belt Excellence. I have paid my belt testing fee ($20 for Yellow through Green; $25 for Brown Belts) I WILL get my Black Belt. I want to wear the Black Stripe on my belt to show my commitment to black and to help inspire other students to do the same. I WILL attend at least two classes each week for the next year. If this is the first time receiving the Black Stripe, I am making a commitment to continue in the program for one year. If this isnt my first time for the Black Stripe, I understand that I am restarting my year and making a commitment to continue for 12 months from my testing date. Nothing will stop me. Quitting is not an option for me. If I get stuck, Ill get through it.

__________________________________ Student Party Name (Printed) __________________________________ Date Signed

The Black Stripe

__________________________________ Student Signature

I would like pay my next testing fee in advance so that I can receive my next belt now. Ill put it where I can see it every day for motivation. I understand that I cant wear the belt until Im promoted for it.
Office use only:

_____________________ Testing Approved by:

_____________________ Test first week of:

_____________________ Belt Fee paid

_____________________ Student promoted on:

Enrollment Agreement for Students making the Commitment to Black Belt

I understand that Black Stripe is optional, and that I may take classes on a month-to-month or quarter-to-quarter basis for as long as I wish without making a commitment to Black Belt. That said, I want to earn the Black Belt. I understand that making a commitment to Black Belt and wearing the Black Stripe will increase the likelihood that I will be successful in this goal. With the Black Stripe, I make the commitment to work through sticking points, find solutions to problems that may threaten my progress, and further develop my perseverance and persistence. I am deciding in advance that I will not quit.

Additional Benefits: w/o Black Stripe

w/Black Stripe

Belt Testing Fee for Yellow through Green Belts $20.00 $10.00 rd nd st Belt Testing Fee for 3 , 2 , 1 Brown Belt $25.00 $12.50 The first time you take the Black Stripe, making a commitment to Black Belt, your belt testing fee is waived. Half price movie night admission for your children 10% off summer camp admission for your children 20% off shirts, uniforms, and sparring gear 20% off any C.O.B.R.A. Self Defense training program for kids or adults 20% off admission to any seminar with a guest instructor (for example, Kevin Secours, or Ed Parker) 25% off a new enrollment for a member of your family.

In exchange for these tangible and intangible benefits, we agree:

1. to remain in the karate program for 12 months from the date of this test; 2. to attend an average of 2 classes per week over the next 12 months; 3. to make up missed classes, either by attending additional group classes, scheduling private coaching sessions, attending camps or clinics or by practicing on individually for an amount of time equal to the class time missed; 4. to demonstrate leadership by helping others reach their goals in the program; 5. to demonstrate self control, on and off the mat, and to use the fighting skills learned appropriately; 6. to make timely payments of tuition during this period. We understand that tuition is due for students in the BLACK BELT PROGRAM whether class is attended or not. I understand that there are two agreements involved; I am making a commitment to participate in the program, and you are also making a commitment to pay tuition whether or not I attend class. I understand that a financial commitment will help me stay focused and working towards Black Belt. Since I will pay tuition whether I come to class or not, I will be more likely to actually come to class. I understand that each test at which I receive the Black Stripe is a renewal of my commitment to Black Belt, and has the effect of restarting my one-year commitment. Our commitment is from ___________________________ to ___________________________.
Start Date End Date

___________________________
Student Name (Printed)

___________________________
Student Signature

___________________________
Date Signed