RO INSLER TAEKWONDO

973-777-4741 – Fax 973-777-4742 – Cell 201-697-8799 - RoInslerTKD@gmaill.comwww.RoInslerTKD.com

ADVANCED BELT TEST: RED - HIGH RED - BROWN

Write your name (the student's name) on the line below, as you want it to appear on the Certificate of Rank:

*_______________________________________________*

 


Student Info:

.                                               . Last Name

 

.                                               . First Name          

 

.                                               . M. I.          -          Nickname

.                                               . Address

.                                               . Town

.                                               . State        -         Zip

.                                   .

Date of  Birth

.                                        .

Cell Phone #

.                                            . Student’s Email

Emergency Info:

.                                                .

1. Spouse's or Parent's Name

 

.                                                .

2. Spouse's or Parent's - Cell #

 

.                                                .

3. Other Emergency Contact Name

.                                              .

1. Spouse's or Parent's Email

.                                              .

2. Other Parent's Email

.                                              .

3. Other Emergency Contact's Cell #

Promotion Info - For Official School Use Only - Completed by Instructor

.                                            . Present Rank & Belt Color

.                                            . Rank & Belt Testing for

.                                            . Color / Belt Size Needed / Tape

.                                            .

Test Date & Time  -  Fee

.                                            .

Certificate I.D. #

.                                            .

Grade / Comments

RED or HIGH RED, $40 - BROWN, $50 - Payment in CASH preferable, or check to CASH