CCIKA Karate Exam Spring 2023

June 9-13, 2023

Dojo Name *

First Name *

Last Name *

Belt Color *

Belt Size *

Class Day *

Time *

Address

City

State

Zip

Gender *

Birth Date * +

Age *

Belt Color

Length of Training 🛈

Rank / Kata

Email *

Exam Fees

Exam Fee *

$45

$40 (Elite Team Members Only)

Student / Adult Contact

Relationship to Participants: *

Parent/Guardian (under 18 yrs.)

Self (18 + yrs.)

Parent/Guardian Name *

Chief Instructor: Hanshi James Carter

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