Black Belt Test Application Form | American Institute of Kenpo (AIK)

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❖ Process

Amount

$275.00

Black Belt Test Application

▻ New Student Applicant's Information

To be considered for the:

October 19th, 2024
Black Belt Test

Candidates must submit this Black Belt Test Application by:

July 26th, 2024

Note:

By completing this application you are not guaranteed to be eligible to test for black belt.
Completing this application in a timely manner is required to be able to be considered for this Black Belt test.
Payment cannot be made until successful completion of the 2nd Prescreening.

Black Belt Test Applicant's Information

DOB

First Name

Last Name

Limitations & Notes

Gender

Male

Female

Applicant's Name For Certificate If Different

Applicant's Black Belt Rank To Be Tested For

Program

Senior Black Belt Rank

Junior Black Belt Rank

▻ Belt Size

One rank appropriate belt is included with the Black Belt testing. Additional belts can be ordered at the time of a belt test.

Note:

It is recommended to increase your belt size by one when you promote from a Brown Belt Rank to a Black Belt Rank.
Larger senior belt sizes are available. Select "Larger Belt Size" then contact AIK for additional information.
Belt length can vary by up to 5 inches.

Each additional belt in this size is:

Select a Program, Target Rank, and Belt Size to see the amount each addtional belt is.

# Of Additional Belts

Black Belt Size Chart

Belt Size

Size 1

Size 2

Size 3

Size 4

Size 5

Size 6

Size 7

Size 8

Size 9

Size 10

Senior Belt

95"

100"

105"

110"

115"

120"

125"

130"

135"

140"

Junior Belt

92"

97"

103"

109"

114"

120"

128"

139"

▻ Rank Certificate

The American Institute of Kenpo will provide one 13" x 19" Rank Certificate with the Black Belt testing.

Each additional Rank Certificate is:

$100.00

# Of Additional Certificates

▻ AIK Black Belt Challenge Coin

The American Institute of Kenpo will provide one Challenge Coin with the Black Belt testing.

Additional Challenge Coins are available for order directly from AIK.

Each additional Challenge Coin is:

$20.00

# Of Additional Coins

▻ Black Belt Test Commemorative Shirt

The American Institute of Kenpo will provide one Black Belt Test Commemorative Shirt with the Black Belt testing.

Additional shirts will be available for order through the Online Shop after the belt test.

Each additional Commemorative Shirt is:

$40.00

# Of Additional Ch Small Shirts

# Of Additional Ch Medium Shirts

# Of Additional Ch Large Shirts

# Of Additional Ad Small Shirts

# Of Additional Ad Medium Shirts

# Of Additional Ad Large Shirts

# Of Additional Ad X-Larger Shirts

# Of Additional Ad 2X-Large Shirts

# Of Additional Ad 3X-Large Shirts

▻ Your Black Belt Lineage Print

Each 13" x 19" Black Belt Lineage Print with your name on it is regularly $100.00.

Each Black Belt Lineage Print ordered at the time of your Black Belt Test is discounted to:

$75.00

# Of Black Belt Lineage Print

▻ Black Belt Keychains

Black Belt Keychains can be ordered at the time of a belt test.

Please note that the price varies depending on the rank.

Senior Rank Keychains

$25.00

# Of Sr. 1st Degree Black Belt Keychains

$30.00

# Of Sr. 2nd Degree Black Belt Keychains

$35.00

# Of Sr. 3rd Degree Black Belt Keychains

$40.00

# Of Sr. 4th Degree Black Belt Keychains

$26.00

# Of Sr. 5th Degree Black Belt Keychains

Junior Rank Keychains

$25.00

# Of Jr. 1st Degree Black Belt Keychains

$30.00

# Of Jr. 2nd Degree Black Belt Keychains

$35.00

# Of Jr. 3rd Degree Black Belt Keychains

$40.00

# Of Jr. 4th Degree Black Belt Keychains

$26.00

# Of Jr. 5th Degree Black Belt Keychains

▻ Meal Choice

The American Institute of Kenpo will provide lunch during the Black Belt Testing process. Though we will do our best to meet your dietary needs, should your diet require something extraordinary, you may want to bring additional food. Please check in the week before the belt testing to select you meal.

Meal Selection Week:

October 7th - October 11th, 2024

I understand and know when I need to place my meal order.

▻ Black Belt Promotion Requirements & Acknowledgments

Please acknowledge that the applicant (and parent/guardian if under 18) is aware of the following requirements to be eligible to test for Black Belt:

1st Prescreening Date

July 29th - August 2nd, 2024

All candidates will be evaluated by a qualified senior ranking black belt. They will demonstrate and be evaluated on their knowledge of the required information. This will include all techniques and forms they have learned to date.

I understand that attending classes during the 1st Prescreening week is required for Black Belt Testing eligibility. I verify that I can and will attend classes on the week of the 1st Prescreening.

2nd Prescreening Date

September 2nd - September 6th, 2024

Candidates for black belt testing must demonstrate a working knowledge of all techniques and forms they have learned to date. The current rotation of information needs to be presentation ready.

Note:

Candidates must be on track or they will be removed from the testing list.

I understand that attending classes during the 2nd Prescreening week is required for Black Belt Testing eligibility. I verify that I can and will attend classes on the week of the 2nd Prescreening.

I understand that I need to know all required Sets, Forms, and Techniques that I have learned up to this point to be eligible to continue the Black Belt testing process. I acknowledge that I need to have the required Sets, Forms, and Techniques that I have learned presentation ready (be able to perform them at a level of performance acceptable for Black Belt testing) or I will not be able to continue with the Black Belt testing process.

Payment Due Date

September 6th, 2024

The payment for the Black Belt test is due. If there is any additional items the applicant wants to add or remove from their Belt Test list this is the last chance to alter what they will be receiving. There is no refund for items ordered after this date.

I understand that prior to making payment for my Black Belt test I can add or remove any Black Belt test items selected above by contacting AIK. I acknowledge that once I make my payment for the Black Belt test all items I have requested will be ordered and that there can be no further change to the selected items.

I understand that once I make payment for my Black Belt test that, in accordance with the Refund Policy below, no refund will be issued regardless of my eligibility or ability to participate in the Black Belt test.

Book Report Due Date

(Senior Ranks Only)

September 6th, 2024

Black Belts should have a working knowledge of the evolution of the martial arts in order to gain a better understanding of physical, mental, and emotional benefits as they apply today, and how they applied it in the past. Candidates are required to not only read the following books, they are encouraged to spend time thinking about how the lessons of the past can help them live in the present with honor and integrity. Candidates are required to write a brief essay over the book they have read.

Candidates testing for 1st Degree Black Belt:

Bushido by Inazo Nitobe

Candidates testing for 2nd Degree Black Belt:

The Art of War by Sun Tzu

Candidates testing for 3rd Degree Black Belt:

Meditations on Violence by Sgt. Rory Miller

Candidates testing for 4th Degree Black Belt:

The Gift of Fear by Gavin De Becker

Candidates testing for 5th Degree Black Belt:

Book of 5 Rings by Miyamoto Musashi

I understand that only those testing for Senior Black Belt Ranks are required to submit a Book Report. I acknowledge that this report must be submitted prior to or at the same time as I submit the payment for my Black Belt test. I understand that if I fail to provide the Book Report in a timely manner that I will not be able to continue with the Black Belt testing process.

Value Report Due Date

September 6th, 2024

All Black Belts should have a firm understanding of traditional values. That understanding is their counterbalance and a guiding force for the tremendously destructive knowledge that is possessed. All candidates will need to complete a report including a full description of the value - from their point of view, how they feel it benefits others, and how they have used it in their life.

Candidates testing for 1st Degree Black Belt:

Trust

Candidates testing for 2nd Degree Black Belt:

Perseverance

Candidates testing for 3rd Degree Black Belt:

Humility

Candidates testing for 4th Degree Black Belt:

Courtesy

Candidates testing for 5th Degree Black Belt:

Mastery

I understand that I am required to submit a Value Report. I acknowledge that this report must be submitted prior to or at the same time as I submit the payment for my Black Belt test. I understand that if I fail to provide the Value Report in a timely manner that I will not be able to continue with the Black Belt testing process.

3rd Prescreening Date

October 7th - October 11th, 2024

Candidates for Black Belt testing must demonstrate a working knowledge of all techniques and forms they have learned to date. The current rotation of information needs to be presentation ready.

Note:

Candidates must be on track or they will be removed from the testing list.
Candidates removed from the testing list at this point will not receive a refund.

I understand that attending classes during the 3rd Prescreening week is required for Black Belt Testing eligibility. I verify that I can and will attend classes on the week of the 3rd Prescreening.

I understand that I need to know all required Sets, Forms, and Techniques to be eligible to continue the Black Belt testing process. I acknowledge that I need to have the required Sets, Forms, and Techniques presentation ready (be able to perform them at a level of performance acceptable for Black Belt testing) or I will not be able to continue with the Black Belt testing process.

Black Belt Test & Promotion

October 19th, 2024

Candidates must attend the belt test to receive promotion. Details are available on the Black Belt Testing Process & Test Information page.

Note:

There is NO MAKE UP TESTING process. Students unable to attend the testing process for any reason will not receive a refund.

I understand that I must attend the Black Belt Test and Promotion. I am aware of the date and times for the Black Belt Test and Promotion (see the Black Belt Testing Process & Test Information page for details).

I understand that, should my behavior and/or actions at any time during or after the Black Belt Test and Promotion, be unbecoming of a Black Belt, and I fail to rectify that behavior, my behavior and/or actions can and will result in my removal from the Black Belt Test and Promotion along with the automatic revocation of my rank and honor without refund or reimbursement.

▻ Participation Agreement

The American Institute of Kenpo, all instructors, and associates will hereby be referred to as the Presenters.

WAIVER OF RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY

In consideration of your acceptance as a member of and participant in the AIK Black Belt Test and Rank Promotion, I do hereby, for myself, my heirs, executors and administrators waive, release, discharge, covenant not to sue, and agree to indemnify and save and hold harmless any and all rights and claims for damages which I may have or may accrue to me against the Presenters of the AIK Black Belt Test and Rank Promotion, owners and leasers of premises on which the AIK Black Belt Test and Rank Promotion is located and against any participant for any and all damages which may be sustained by me, in connection with and my association with the AIK Black Belt Test and Rank Promotion including those which may arise out of travel to, participation in, and returning from the AIK Black Belt Test and Rank Promotion.

I understand the nature of the activities and believe that my experience, health, and capabilities to be qualified to participate in the AIK Black Belt Test and Rank Promotion and associated athletic events, trainings, classes, and/or seminars. I understand that when participating in any sport, athletic event, training, class, and/or seminar there is inherent risk and therefore this may involve risk and dangers of bodily injury, including permanent disability, paralysis, and death. These risks and dangers may be caused by my own actions, or inactions and/or the actions of others participating at the Presenters facilities, and athletic events/trainings/self defense and health related seminars and classes to include the AIK Black Belt Test and Rank Promotion. I acknowledge that it is recommended that before undergoing any form of exercise, an examination or consultation with your doctor is suggested.

COVID-19 WAIVER

I understand and acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed or infected by COVID-19 by visiting the Presenters facilities and premises, and that such exposure or infection may result in personal injury, illness, permanent disability or death. I understand that the risk of becoming exposed or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, and I completely release, covenant not to sue, discharge, and hold harmless the Presenters, agents, owners, representatives, and employees from any and all liabilities, claims, suits, actions, losses, damages, costs or expenses of any kind if I do become exposed or infected. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the Presenters, and the employees, agents, owners, representatives, and employees, whether a COVID-19 infection occurs before, during, or after visiting the Presenters facilities and premises and/or my participation in any of the Presenters events.

Refund Policy

I understand and accept that if I am unable to pass the 2nd Prescreening that I will not be eligible for this AIK Black Belt Test and Rank Promotion. I will not be charged for any of the above listed items. No items will be ordered.

I understand, assuming that I can successfully complete the requirement to be eligible, that select items can be held for the next AIK Black Belt Test and Rank Promotion. Items that cannot be held include the Rank Certificate and the Black Belt Test Commemorative Shirt. I acknowledge that to participate in any future AIK Black Belt Test and Rank Promotion that I will need to submit additional payment for the relevant Rank Certificate and the Black Belt Test Commemorative Shirt.

CONSENT TO ATTEND

I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it and have signed it freely and without an inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by the law and agree that if any portion of this agreement is held to be invalid that the balance, notwithstanding, shall continue in full force and effect.

I fully understand that any medical treatment given to me will be First-Aid type treatment only.

I further consent that any pictures furnished by me or any pictures taken of me in connection with any activities can be used for publicity, promotion or media showing, and I waive compensation in regard thereof.

ACKNOWLEDGMENT OF APPLICATION AND ACCEPTANCE

The undersigned applicant has read and understands the provisions of this application and acknowledges that no other verbal agreements have been made. The applicant accepts all provisions of this application.

In the event that the applicant is not of legal age (if under 18) the parent/legal guardian attests that they have read the previsions of this application with the applicant. The undersigned parent/legal guardian and the applicant both acknowledge and understands the provisions of this application and acknowledges that no other verbal agreements have been made. The parent/legal guardian and the applicant accepts all provisions of this application.

Applicant’s Legal Name

Applicant’s Phone Number (If 18 or older)

Applicant’s Email (If 18 or older)

Applicant Signature

Parent’s/Legal Guardian’s information and consent is required if the Applicant is under 18 years old.

Parent’s/Legal Guardian’s Legal Name

Parent’s/Legal Guardian’s Phone Number

Parent’s/Legal Guardian’s Email

Parent’s/Legal Guardian’s Signature

Waver

The American Institute of Kenpo, all instructors, and associates will hereby be referred to as the Presenters.

WAIVER OF RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY

COVID-19 WAIVER

Refund Policy

Should I pass the 2nd Prescreening, and I submit payment, all requested items will be ordered. I understand that, due to the nature of these items, there will be no refund for those items I requested nor will I receive those items until such time as I successfully complete the AIK Black Belt Test and Rank Promotion.
 
I understand, assuming that I can successfully complete the requirement to be eligible, that select items can be held for the next AIK Black Belt Test and Rank Promotion. Items that cannot be held include the Rank Certificate and the Black Belt Test Commemorative Shirt. I acknowledge that to participate in any future AIK Black Belt Test and Rank Promotion that I will need to submit additional payment for the relevant Rank Certificate and the Black Belt Test Commemorative Shirt.

CONSENT TO ATTEND

I fully understand that any medical treatment given to me will be First-Aid type treatment only.

ACKNOWLEDGMENT OF APPLICATION AND ACCEPTANCE
The undersigned applicant has read and understands the provisions of this application and acknowledges that no other verbal agreements have been made. The applicant accepts all provisions of this application.
 
In the event that the applicant is not of legal age (if under 18) the parent/legal guardian attests that they have read the previsions of this application with the applicant. The undersigned parent/legal guardian and the applicant both acknowledge and understands the provisions of this application and acknowledges that no other verbal agreements have been made. The parent/legal guardian and the applicant accepts all provisions of this application.

Black Belt Applicaiton Summary

Your Application Has Been Submitted!