| CLEAN ROOM (Responsibility) | M | T | W | T | F | S |
| Make Bed | ||||||
| Put Personal Belongings away | ||||||
| SELF CARE (Self Confidence) | ||||||
| Brush Teeth | ||||||
| Take a Bath/shower | ||||||
| Put dirty clothes in laundry | ||||||
| EDUCATION (Character/Self Discipliine) | ||||||
| Complete homework | ||||||
| Use Black Belt effort in class | ||||||
| Use Black Belt respect for teachers and classmates | ||||||
| FAMILY (Respect) | ||||||
| Complete assigned chores | ||||||
| Use Black Belt respect for entire family | ||||||
| SELF DEVELOPMENT (Self Discipline/Self Confidence) | ||||||
| Practice Martial Arts for at least 15 minutes | ||||||
| OTHER | ||||||
Please remember to mark anything your parents don't require you to do as "n/a". Thank you!
Student: ___________________________ Parent Signature: ________________________________