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, March 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, March 11, 2023
Time: 3:30 PM - 6:30 PM
Details: 5 Boards Provided (More available for purchase upon request)

Black Belt Practical Test:
Date: Saturday, April 15, 2023
Time: 2:30 PM - 6:00 PM

Registration Deadline: March 10, 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 testing fee includes the referee seminar, written test, board breaking seminar and the self-defence seminar as well as the black belt 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
If the black belt candidate requires a re-test due to a non-passing grade, additional fees will be required for a re-test.

Test Applicant Information

First Name *

First

Last Name *

Last

Name In Hanja/Hangul (Chinese/Korean)

You may put both if you know the translation. Put N/A if you do not know.

Membership Number

Date of Birth

Age

Address *

Address

Street Address

Apt./Building/Suite #

City

State/Province

Zip/Postal

Country

Email Address *

Phone

Dobok Size

Please check your current dobok for reference. A fitting dobok size means wrist bone and ankle bone are visible.

Belt Size

Please check your current belt for reference. A fitting belt means the ends of the belt is at your mid-thigh.

Digital ID Photo (Required For Kukkiwon Certificate Application)

Maximum upload size: 268.44MB

Black Belt 1st Dan/Poom Test Requirement

Minimum 6 Months of regular class training after your Red-Black Belt (1st Kup) Test

Last Promotion Test Date

Minimum 25 Leadership/Vounteer Hours after your Red Black Belt (1st Kup) Test

Leadership/Volunteer Hours

Emergency Contact Information

Emergency Contact Name

First

Last

Relationship to Member Relationship to Member

Emergency Contact Phone Number

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.

Signature

Clear

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

Date

Payment Information

Test to 1st Poom / Dan Promotion Test Fees

GST (5%)

Total

Payment Method

Pay by Cash or Cheque at the school

Consent for Bank Withdrawal (Only for members who have a bank account on file)

Bank Withdrawal Authorization
I/We hereby authorize Jeon Eui Taekwondo to direct my Financial Institution to debit my/our bank account, on file for $577.50 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.