Region 22 Black Belt Classes

Region 22 Black Belt Classes

2026 yearly registration form
Attendance of the Black Belt Classes is

REQUIRED

to be considered for promotion to your next rank.

Please visit the regional website for details at:

www.wtsdaregion22.com/bbclass
Student information
Name*

First NameLast Name
WTSDA student Number*
Instructor Name*
Instructor name if other
School name*
School name if other
Rank*
Date of birth*

MonthDayYear
Date
Age
Student E-mail *
example@example.com
Phone Number*
Please enter a valid phone number.
Terms and Conditions
Student Signature (all ages)*

Clear
Parent/guardian signature (if student less than 18 years old)

Clear
Date*

MonthDayYear
Date
Parent/Guardian/Emergency Contact
Parent/Emergency Contact Name*

First NameLast Name
Parent/Emergency contact relationship*
Parent/Emergency contact Phone Number*
Please enter a valid phone number.
Parent/ Emergency contact Email*
example@example.com
Payment

My Products

2026 Black Belt Class unlimited classes/any location

$50.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

If you have any questions, please email region22asstrd@gmail.com
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