Student Black Belt Packet

STUDENT BLACK BELT PACKET

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Guardian Information (if student is minor)

Phone:    Email:

Emergency & Medical Information

Emergency Contact Name:

Relationship:    Phone:

Physician Phone:    Insurance Provider:

Eligibility & Testing Requirements

The following items are required prior to approval to test for black belt. Check each item that has been completed or acknowledged.

Minimum age requirement met as determined by the organization
Minimum time-in-rank requirement satisfied and documented
Required attendance and logged hours completed
Demonstrated required curriculum and syllabus progression
No outstanding disciplinary actions or financial holds

Testing Fee & Payment

Paid in full prior to testing date
Payment arrangement made with administration

Policies, Consent and Releases

Assumption of Risk and Release: By signing below, I acknowledge that martial arts training and testing involve physical contact, strenuous exertion and inherent risks including but not limited to sprains, fractures, and other injuries. I certify that the student is voluntarily participating and that I assume all risks associated with participation. I voluntarily release, waive, and discharge the school, its owners, instructors, agents, employees and representatives from any and all claims, liabilities or demands for injury, loss, or damage arising from participation, except to the extent caused by gross negligence or willful misconduct.

Emergency Medical Authorization: In the event of injury or illness, I authorize the teaching staff or designated agent to obtain emergency medical treatment for the student if I cannot be reached. I agree to be responsible for all costs incurred for such care.

Photo / Video Release: I consent to the capture and use of photographs or video of the student for promotional, instructional, or accreditation purposes. I understand no compensation is provided and images may be used in print or electronic media.

Refund and Testing Policy: Testing fees are non-refundable except as required by law. Students must meet documented prerequisites to be eligible for testing. The organization reserves the right to postpone or deny testing for safety, disciplinary, or administrative reasons.

Indemnification: I agree to indemnify and hold harmless the school and its affiliates from any claims, demands, actions, or causes of action brought by or on behalf of the student or third parties arising out of participation, except to the extent caused by gross negligence or willful misconduct of the school.

Acknowledgment (check to indicate agreement):

I have read, understand, and agree to the Assumption of Risk and Release above.
I authorize emergency medical treatment as described above.
I consent to the Photo / Video Release terms above.

Student Code of Conduct

Students and guardians agree to abide by the following standards while training and during testing events:

Demonstrate respect to instructors, examiners, and fellow students.
Maintain required attendance and punctuality.
Refrain from abusive, disruptive, or unsafe conduct.
Wear approved uniform and gear during training and testing.

Instructor Evaluation (to be completed by instructor)

Technique Proficiency (attorney-style evaluation):

Instructor Printed Name:

Date of Evaluation:

Certification & Signature

By signing below, I certify that the information provided in this Student Black Belt Packet is true and complete to the best of my knowledge. I accept and agree to abide by the policies, waivers, and acknowledgments contained in this packet. If signing as a parent/guardian, I represent that I have legal authority to execute this agreement on behalf of the student.

If signer is signing as Parent/Guardian: I certify that I am the student's parent or legal guardian and have authority to sign.

Sign Now