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Belt Test Form
Students Name
*
Email Address
Class Day/Time
*
Class Day/Time
Mon/Wed 4:00
Mon/Wed 4:45
Mon/Wed 5:30
Mon/Wed 6:15
Tues/Thurs 4:00
Tues/Thurs 4:45
Tues/Thurs 5:30
Tues/Thurs 6:15
Current Belt Rank
*
Parents, Please Select from the Following
Behavior In Public
*
Excellent
Good
Fair
Poor
School Learning (ie. Focus, completion of assignments, etc.)
*
Excellent
Good
Fair
Poor
Behavior At Home
*
Excellent
Good
Fair
Poor
Interaction with siblings (if applicable)
*
Excellent
Good
Fair
Poor
N/A
Students, Please complete the following
Have you stayed focused on your goals during the past quarter?
If not, what do you plan to do to refocus this quarter?
What would you like to improve upon this quarter? Grappling, Sparring, Self-Defense, etc.
If you are not currently enrolled in Black Belt Club, do you plan on joining to improve your skills?
Do you plan on attending ceremony?
*
Yes
No
If yes, how many people plan on attending?
Parent's Signature
*
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