Black Belt Promotion Test Registration Form | 2nd Poom / Dan

Promotion Test | Black Belt 2nd Poom/Dan

Black Belt Promotion Test Information

Referee Seminar, Written Test and Essay Submission:
Date: Saturday, July 1, 2023
Time: 9:00AM - 10:00AM
Essay Topic: "What a Black Belt Means to me” (Minimum 500 words)

Board breaking, Self-defence Seminar:
Date: Saturday,July 1, 2023
Time: 10:00AM - 12:00 PM
Details: 5 Boards Provided (More available for purchase upon request)

Black Belt Practical Test:
Date: Saturday, August 26, 2023
Time: 7:00 PM

Registration Deadline: June 28, 2023 (Complete Registration form including payment)

Black Belt Promotion Test Registration Fee: 2nd Dan/Poom $800.00 Plus Tax (Late Registration will incur in a $50 late fee)

Leadership Program and Instructor Subsidy up to $100.00 and $200.00 respectively
(Application form, which is attached in the black belt test email, must be submitted together with this registration form, an approval/rejected email will send to you within 3 business days)

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

Membership Number

Date of Birth

Age

Address *

Address

Street Address

Apt./Building/Suite #

City

State/Province

Zip/Postal

Country

Email Address *

Phone

Dobok Size

Poom Uniform will be used for 14 years old and Under | Dan Uniform will be used for 15 years old and older

Belt Size

Current Size on Belt

Digital ID Photo (Kukkiwon Certificate Application)

Maximum upload size: 268.44MB

Leadership Program / Instructor Program Subsidy Application Form

Maximum upload size: 268.44MB

An seperate email will be sent to you if the application is approved.

Black Belt 2nd Dan/Poom Test Requirement

Minimum 1 Year of regular class training after your Black Belt 1st Poom/Dan Test

Last Promotion Test Date

Minimum 50 Leadership/Vounteer Hours after your Black Belt 1st Poom/Dan 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 2nd 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 $735.00 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.