Congratulations!
 
You have earned the opportunity to demonstrate your skills to the Black Belt Panel and move up to the next belt level. 

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INFO:   Please note that this form contains limited capacity items which are sold out. They are displayed grayed out and/or are not selectable.





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Registrant Fee: $0.00


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Billing and Payment
Billing and payment processing for Businesses' events is performed by Member Solutions, Inc. ("MSI"), and this contract is specifically assigned to MSI for all such purposes. Customer knowingly and irrevocably authorizes MSI to charge electronically Customer's bank account and/or credit card for any and all amounts due for Customer's, and anyone registering under Customer's, attendance and participation in the Event. Please note, you may see all or any portion of the following on your bank or credit card statement: "MSI*CONNELLYSACADEMY 8882448044 ONLINE REG FEE". Any returned payment will be assessed a $25.00 fee. Any unsuccessful electronic transaction is subject to a $10.00 processing fee. MSI is not responsible for any bank fees incurred by Customer. MSI has the sole right to resubmit returned or declined items (plus applicable fees) without prior notice. BILLING INQUIRIES -- 888-244-8044 or by mail to PO Box 297, Hatboro, PA 19040.

Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

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Registration inquiries:
Grandmaster Connelly: info@connellysacademy.com
Ms. Mason: amason@connellysacademy.com
847-568-0912
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ADVANCEMENT FEES
The fee structure is based on three belt levels, Beginning, Intermediate and Advanced.

The Beginning Level would include students promoting to 1 Yellow Stripe, 2 Yellow Stripes, Yellow Belt and Green Stripe.  Students who are currently White Belts are in this level.  The fee is $35.

The Intermediate Level would include students promoting to Green Belt, Blue Stripe and Blue Belt.  The fee is $40.

The Advanced Level would include students promoting to Red Stripe, Red Belt, Black Stripe and Black Belt Candidate.  The fee is $45.
If you train at more than one program location, please check all that apply.
Levy Center - Evanston Recreation
Chandler Newberger - Evanston Recreation
Highland School - Skokie
Morton Grove Park District
MAGE - Chicago
Northfield Park District
Rogers Park Montessori
Roycemore School
BH JCC - Chicago
District 65 Enrichment (before/after school)
Other
If you checked District 65, please select the individual school. 
Not Applicable
Bessie Rhodes
Dawes
Dewey
King Arts
Kingsley
Lincoln
Lincolnwood
Oakton
Orrington
Walker
Washington
Willard
Who is your Instructor or Program Leader?
Grandmaster Joseph Connelly
Master Michael Eisenstein
Master Sterling Goodrich
Ms. Tamar Gutman
Mr. Martin Horn
Ms. Emily Kuhn
Mr. Brooke Lester
Ms. Ellen Lonnquist
Ms. Anne Mason
Mr. Nicholas Peebles
Mr. Tim Peebles
Mr. Manel Valdes-Cruz
Mr. Gary Vernon
Youth students are required to have a recommendation from the instructor.  
TERMS AND CONDITIONS
"As a participant (or as a the parent/guardian of the participant under the age of 18) in the Connelly’s Academy, Inc. promotion advancement/testing, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any illnesses, injuries, including death, damages or loss that I (or my child) may sustain as a result of participating in any and all activities connected with or associated with the advancement/test. I agree to waive and relinquish all claims I may have as a result of my ( or my child's ) participating in the event against its officers, agents, servants, employees and sponsors. Photographs and videos of me or my child as a Connelly's Academy student may be used in public relations program media and prepared materials and advertisements. I have read and fully understand the above promotion advancement/testing details and participation agreement."
Check this box to indicate that you have read and agree to all of the above terms & conditions
If you registering a child as his/her parent or a guardian, please enter your name.
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