11:00 AM Testing for White with orange stripe or white with black stripe Saturday, Nov 15th, 2025 - YOUTH East Silver Spring ES

Student Name*

First NameLast Name
Parent Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name of primary instructor*

Coach VCoach ChrisCoach ZachCoach DavidCoach NinaCoach SkylarCoach JamesInstructor's name is not listed above
Your Instructor Name*
Date of Belt Test*

Saturday, Nov 15th, 2025
Belt Test Mode*

Received an Invitation from Kaizen Karate OfficeMake up Belt Test
Current belt rank*

White ( All students start at this belt rank even if they do not have a belt )
Testing for the following belt rank (must test for the next belt rank in order - no skipping belt ranks)*

White with orange stripe (3-4 yrs old)White w/black stripe (5yrs and older)
Class location (eg. East Silver Spring ES, Cleveland Park Club, etc)*
What color stripes do you currently have on your belt?*

No Stripesblue (positive attitude)yellow (technique)green (sparring)orange (summer camp)purple (fitness / flexibility - not mandatory - optional)

Select the belt rank you are testing for below (only choose 1)*

White with orange stripe E - certificateYou will get an electronic certificate from Kaizen Karate. If you opting for this option.

$50.00

White with orange stripe Physical - certificateYou will get a physical certificate from Kaizen Karate. If you opting for this option. Please do share your shipping address.

$60.00

White w/black stripe E - certificateYou will get an electronic certificate from Kaizen Karate. If you opting for this option.

$50.00

White w/black stripe Physical - certificate You will get a physical certificate from Kaizen Karate. If you opting for this option. Please do share your shipping address.

$60.00

Enter coupon

Total

$0.00

Shipping Address ( We will ship Physical Certificate to this address )*

Street Address

Street Address Line 2

CityState

Zip Code
Do you consent to video recording of your child during the Belt Exam Day for promotional purposes?*

Yes, I consentNo, I do not consent.
Terms and Conditions*
By checking 'Yes', I give my consent for video recording of my child during the Belt Exam Day for promotional use. I understand that the videos may be shared on various platforms including social media.
Signature*

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