Black Belt Promotion Test Registration Form | 1st Poom / Dan

Promotion Test | Black Belt 1st Poom/Dan

Black Belt Promotion Test Information

Referee Seminar, Written Test and Essay Submission:
Date: Saturday, November 11, 2023
Time: 2:30 PM - 3:30 PM
Essay Topic: "My Taekwondo Journey" (250 - 500 words, typed) 

Board breaking, Self-defence Seminar:
Date: Saturday,November 11, 2023
Time: 3:30 PM - 5:30 PM
Details: 5 Boards Provided (More available for purchase upon request)

Black Belt Practical Test:
Date: Saturday, December 9, 2023
Time: 7:00 PM (Subject to change)

Registration Deadline: Monday, November 6, 2023 (Complete Registration form including payment)

Black Belt Promotion Test Registration Fee: 1st Dan/Poom $650.00 Plus Tax (Late Registration will incur in a $50 late fee)

The registration fee includes the following.

  • Referee seminar and Written test ($50.00 + GST for re-test)
  • Board breaking seminar (Includes 5 boards) and Self-defence seminar ($100.00 + GST if you wish to attend the seminar again)
  • Black belt practical test ($200.00 + GST for re-test)

If test is completed with a passing grade, the following are included in each black belt test,

  • Adidas Black/Poom Belt Dobok
  • Adidas Black/Poom Belt
  • Kukkiwon Certificate Application

Test Applicant Information

First
Last
You may put both if you know the translation. Put N/A if you do not know.
Address
Street Address
Apt./Building/Suite #
City
State/Province
Zip/Postal
Country
Please check your current dobok for reference. A fitting dobok size means wrist bone and ankle bone are visible.
Please check your current belt for reference. A fitting belt means the ends of the belt is at your mid-thigh.
Maximum upload size: 268.44MB

Black Belt 1st Dan/Poom Test Requirement

Emergency Contact Information

Emergency Contact Name
Emergency Contact Name
First
Last

Waiver Information

I hereby give permission for myself/my child to participate in Jeon Eui Taekwondo Black Belt Promotion Test. I understand that there is no refund on black belt promotion test fee. For extenuating circumstances, the black belt test may be postponed by providing written notice within 48 hours after the test. Only one postponement will be allowed and it must be re-scheduled within one year. Having read and understood all the information on this form, I hereby allow myself/my child to attend Black Belt Promotion Test. The Waiver Forms that I have signed at Jeon Eui Taekwondo will also apply to the Black Belt Promotion Test.

Sign by parent or legal guardian if under 19 years of age

Payment Information

Payment Method

Bank Withdrawal Authorization
I/We hereby authorize Jeon Eui Taekwondo to direct my Financial Institution to debit my/our bank account, on file for $682.50 for the black belt promotion test fees.
If any payment is returned by the Bank for any reason, I/we will be responsible for Non-Sufficient Funds (NSF) and/or administration charges.
I/We, the undersigned, have read, understood, and agree to the terms and conditions of this agreement.