ITA Black Belt Grading Application Form Dec. 2021
The ITA Winter Black Belt Grading will take place in  Applewood Community Centre, Swords, on Sunday Dec 12th

This application form must be completed by the instructor for all applicants going forward for the ITA black Belt grading.

The Deadline for submitting applications is Sunday Nov 21st.

A passport style photo of each candidate must also be submitted on applying to sryan@taekwondo.ie

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Candidate full name (ensure correct spelling) *
Candidate Age (minimum age 13) *
Date of Birth *
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Nationality (This will be printed on certificate) *
Gender *
Last promotion date *
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Current grade *
ITA School Name *
Instructor's Name *
Instructor's ITF Instructor Plaque number *
Instructor's email address *
Candidate email *
Candidate phone number *
Have you completed an ITA Preliminary Black Belt test prior to this black belt grading *
Date of Preliminary Black Belt grading *
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Name of examiner who conducted the Preliminary black belt grading *
Note; Any issues that are relevant to the performance of a candidate and their subsequent grading result must be presented in writing with the grading application (e.g. applying for an executive grade, medical, physical, psychological), a doctor’s note to accompany where appropriate. These items will be discussed, initially by the technical director, with the instructor of the candidates and subsequently with the panels in advance of the test. All such information will be treated with discretion and in confidence. Please email details to the ITA Secretary General (sryan@taekwondo.ie) when applying to test.
Are you taking any form of medication for any cardiac condition (including aspirin & warfarin) ? *
Do you or have you felt a sensation of "blacking out" during or after training? *
Do you or have experienced any chest pains or chest tightness during or after physical activity? *
Do you have a diagnosed bone or joint condition that could be aggravated by physical activity? *
Are you aware, through your own experience or on medical  advice, of any  reason why you should not take part in strenuous high intensity physical activity ? *
Is your BMI greater than 28 ? *
Are you pregnant, or have you been pregnant in the past three months? *
Are you aware, through your own experience or a doctor’s advice, of any reason why you should seek medical approval before engaging in any form of exercise? *
If you answered yes to any of the above questions you will need a letter from your GP stating that you are "medically fit to take part in a Black Belt Grading"
Do you have any special needs or requirements that the examiners should be made aware of? *
If there is any other condition which may affect participation which the examiners panel should be made aware of? *
Do you accept that participation in the grading involves high intensity activity and the risk of injury? *
Date & Place of any IICs completed during preparation period (Applications for 4th Degree and above)
Do you have a valid ITF plaque? (All ITA instructors, assistant instructors, all Dan grades from 3rd Degree upwards & all examiners must have an up to date ITF plaque, if you do not currently have one please include the 40 Euro annual fee with the application) *
All applicants testing for 4th degree and above must also hold an international instructor/examiner certificate. The 150 Euro fee must be included along with the testing fee. You must also complete the ITF online exam as part of the certification process. Email the ITA Secretary General (sryan@taekwondo.ie) for more information.
Please refer to the ITF & ITA Bylaws to make sure you meet all the requirements to be eligible to test. Further information regarding the ITA Black Belt grading including the fee structure & syllabus are available on the ITA website at this link; https://www.taekwondo.ie/blackbelt-grading
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