Student's Full Name*

Parent's Full Name (if under 18 years of age)

Email*

Current Rank*
---WhiteHigh WhiteYellowOrangeGreenPurpleBlueHigh BlueLow BrownBrownHigh BrownBlack JuniorBlack 1st DanBlack 2nd Dan

Requesting Rank*
---High WhiteYellowOrangeGreenPurpleBlueHigh BlueLow BrownBrownHigh BrownBlack JuniorBlack 1st DanBlack 2nd Dan

Payment Options | Cash & Card Payments are to be made directly to Instructor, Mrs. Rush
CashCredit CardCheck (Payable to: ROKKK)

*By selecting this checkbox, I, the undersigned do hereby apply to participate in the promotional examination to be held at Chandler MMA. I do hereby assume any and all responsibility for any and all loses, damages and/or injuries I may sustain or incur if any while attending or participating herein. I hereby waive any and all claims against Chandler MMA and ROKKK and fellow participants of the promotional examination, individually or jointly, for ay losses, damages or injuries. I also agree that any and all photographs taken by Chandler MMA & ROKKK are property of Chandler MMA and ROKKK to be used as they wish. If the undersigned is under 18 years of age, this release must be signed by a parent or guardian.

THE CHECK BOX MUST BE SELECTED IN ORDER TO SUBMIT THIS FORM.

Student e-Signature*

Parent e-Signature (if under the age of 18)