RO INSLER TAEKWONDO

973-777-4741 – Fax 973-777-4742 – TKDteach2@aol.com – www.RoInslerTKD.com

Mailing address: 23-26 Berkshire Road, Fair Lawn, NJ 07410

NOVICE TEST APPLICATION – 1^ST HIGH WHITE TO HIGH YELLOW BELT

Please print, complete and return this form immediately with your payment (see bottom of form**)

Write your name below*, as you want it to appear on your certificate:

*_______________________________________________

Student Info:
_______________________________	_______________________________	_____________________________
Last Name	First Name	M. I. - Nickname
_______________________________	_______________________________	_____________________________
Address	Town	State - Zip
_______________________________	_______________________________	_____________________________
Date of Birth	Home Phone #	Student’s Work Phone #
Emergency Info:	_______________________________ Student’s E-mail Address
1______________________________	2______________________________	3____________________________
Spouse/ Mother / Guardian	Father / Guardian	Other Emergency Contact Name
1______________________________	2______________________________	3____________________________
Work Phone #	Work Phone #	Emergency #
1______________________________	2______________________________	3____________________________
E-mail	E-mail	Relationship to Student
Promotion Info:
_______________________________	_______________________________	____________________________
Present Rank & Belt Color	Rank & Belt Testing for	Color / Belt Size Needed / Tape
________________________________	_______________________________	_____________________________
Test Date & Time	Certificate I.D. #	Grade / Comments

** TEST FEES **

Single Test, $25: ___1^st High White ___2^nd High White ___3^rd High White ___Yellow ___High Yellow

Double Test, $40: ___1^st and 2^nd High White ___2^nd and 3^rd High White ___3^rd High White and Yellow

**Deduct 10% for family discount (not applicable for Double Test)

Payment in CASH preferable OR check payable to “CASH”

Promotion Test will be held at:

___ Thomas Edison School Gym, 37-01 Fair Lawn Ave., Fair Lawn, NJ 07410

___ Fair Lawn Jewish Center, corner of Manor Ave. & Walsh Pl., Fair Lawn, NJ 07410

___ Fair Lawn Heavy Rescue, 16-01 Romaine St., Fair Lawn, NJ 07410

___ ____________________________________________________________________________

_____________________________________________________

Student’s Signature (age 18 & up) or Parent’s Signature (17 & under)