This form must be completed and submitted to the Exam Instructor prior to the pretest and Exam

                      YES, I HAVE:

                                     ( ) Learned and practiced the American Freestyle  Karate Student Creed (page 6), and the Black Belt Creed.

                                     ( ) Memorized the Word of the Month and recited the definition, as well as the action steps.

                                     ( ) Shown improvement in: ICAN -know definition

                                           1. School or workplace

                                           2. Physical fitness

                                           3. Community or family service (neighborhood, home, school, work)

                                    ( ) Been consistently stretching at home for at least 15 minutes a day.

                                    ( ) Attended all required AFSKC  Intramural tournaments.( next one April 2006 )

                                    ( ) Selected at least one witness to attend my exam.

                                    ( ) Have Sponsored a new member to American Freestyle  Karate Club

                                    ( ) Selected my new days of attendance, If Saturday is required, completed 18hrs of class since last test.

   Under 18 only                          

            □ Intent to promote signed by teacher and parent.

           □ Continued to demonstrate respect to parents, teachers and family members.

                                                        (To be initialed by parent or guardian)___________________________

                    Head Instructor___________________ Date_______ Student Signature__________________ Date______

                   School Director___________________ Date_______ Parent or Guardian (if applicable)_______________ Date______


Dear Parents and Teachers:

One of the highest priorities here at American Freestyle Karate Club is to develop well-rounded,

successful, and honest individuals. Prior to considering a child for a belt promotion, we require

satisfactory reports from ALL school teachers and from parents. If a child exhibits a poor attitude or

poor citizenship, we will hold rank testing until there has been a significant improvement.

School Name:_________________________________________________________

1. In my opinion, this student has been performing in a satisfactory manner, is receiving

passing grades, and is respectful of teachers and other students.

Teachers Signature        Contact Phone No.         Agree               Disagree (please explain)                  Current Grade

_____________       ____________         _____             ________________                  __________

_____________       ____________         _____             ________________                  __________

_____________       ____________         _____             ________________                  __________

_____________       ____________         _____             ________________                  __________

_____________      _____________       _____              ________________                  __________

_____________      _____________       _____              ________________                  __________

TEACHER’S – American Freestyle Karate  volunteers throughout the school system to provide school

programs, after-school programs, career days, and show & tell presentations. Contact our

school if you are interested in a Black Belt Instructor Visiting your school. More information

available at 704-483-9471( contact Mr. McCall)

2. My son/daughter has been behaving and cooperative at home.

Parent Signature ________________Agree ______________Disagree (Please explain)_______________

American Freestyle  Karate Club

Required for all students under age of 18