White Stripe

Impact taekwondo

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Student's Name *

First Name Last Name
Select your Current Rank *

White Belt
Respectful Chart

Respect is a way of treating or thinking about someone or something.

List 3 things you did or said that were respectful, every day for 7 days.
Day 1 *
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Day 2 *
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Day 3 *
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Day 4 *
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Day 5 *
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Day 6 *
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Day 7 *
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Parent Signature *

Clear
Yellow Belt
Courtesy Chart

Courtesy is the showing of politeness in one's attitude & behavior towards others.

List 3 courteous things you did daily for 7 days.
Day 1 *
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Day 2 *
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Day 3 *
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Day 4 *
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Day 5 *
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Day 6 *
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Day 7 *
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Parent Signature *

Clear
Purple Belt
Chores/Tasks Chart

A Chore is a routine task, especially a household one.

List up to 3 chores youve completed every day for 7 days.

Return this signed & completed by week 2.
Day 1 *
Day 2 *
Day 3 *
Day 4 *
Day 5 *
Day 6 *
Day 7 *
Congratulations on completing 1 week of chores/task. It is important that you continue to complete your chores/task every week without being told. This continued behavior will demonstrate your responsibility.
Parent Signature *

Clear
Orange Belt
Confidence Challenge

Challenge: Go to 2 of your favorite Restaurants and order your own meal.

Talk with a loud voice and use eye contact. Don't forget to use your manners.
Location *
What did your order? Describe your experience *
Location *
What did your order? Describe your experience *
Parent Signature *

Clear
Green Belt
Self-Control Challenge

Self-Control is the ability to control oneself, particularly one's emotions and desires or the expression of them in one's behavior, especially in difficult situations.

Write about a time when you were mad or frustrated.

Explain how you used Self-Control to better the situation.
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Parent Signature *

Clear
Blue Belt
Selfless Challenge

Being Selfless is when you are thinking of other people before yourself and giving to others without looking for personal gain.

Do as many acts of selflessness on this list. You are not required to do everything listed below.
Challenges

Donate $5 or more to a person or organization of your choice Compliment a friend or a stranger Tape quarters to vending machines Letting someone in line go ahead of you (at grocery store or restaurant) Thank a soldier for his/her service to our country Donate blood Talk or befriend someone you see alone Hold the door open for someone Pick up trash Do a chore for a sibling. Or a task for a coworker Donate Food Pray For Someone Draw a Picture for someone Bake for a Friend Volunteer Babysit for Free Leave a large tip Pay for some one's food
Write a short paragraph on what your experience was like completing one of the selfless challenges above. *
Parent Signature *

Clear
Brown Belt
Responsibility Challenge

1. What does having Responsibilty mean?

2. What are you responsible for?

3. Why is it important to be Responsible?
Write a paragraph answering the questions listed above.
Parent Signature *

Clear
Red Belt
Goal Challenge

A Short term goal is something you want to accomplish soon. Short term goals are usually something you want to complete in a week, a month, or before the year ends.

A Long term goal is something you want to accomplish in the future. Long term goals require time, planning, and dedication. And may require a few short term goals to get there.

List 3 short term goals and 3 long term goals. Write down steps you will take to achieve these goals.
Short Term Goals
Goal #1 *
Goal #2 *
Goal #3 *
Long Term Goals
Goal #1 *
Goal #2 *
Goal #3 *
Parent Signature *

Clear
Advanced Red Belt
Community Service Part 1

Must complete 10 hours of community service
Download the following to fill out as you go
Upload a picture of the document above when completed

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Poom Belt
Community Service Part 2

Must complete 10 hours of community service
Download the following to fill out as you go
Letter of Appreciation

Write a letter (2 page minimum) to your parent(s)/guardian(s) thanking them for everything they have done for you
Upload a picture of the document above when completed and your letter of appreciation.

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Contact Us

(702) 843-0497 Hablamos Español!

Location

276 E Lake Mead Parkway Suite A
Henderson NV 89015
(Walmart Shopping Center)

About Us
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Members

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