PALS Chess Club - Winter Session

Littleton Academy

Chess Club Registration Form

Day and Time: Wednesdays before school from 7:00 - 8:00 a.m.

Winter Session: 2/1, 2/8, 2/15, 2/22, 3/1, 3/8, 3/15, 3/22

Head Coach: 5-time Colorado State Chess Champion, National Master Lior Lapid

Participant Information

First Name *

Last Name *

Student's Birthday * 🛈 +

Grade *

Level of Experience *

Register a second child? ($20 sibling discount)

Yes

First Name

Last Name

Student's Birthday 🛈 +

Grade

Level of Experience

Register a third child? (additional $20 sibling discount, $40 off in total)

Yes

First Name

Last Name

Student's Birthday 🛈 +

Grade

Level of Experience

Does your child have any medical issues or allergies that we should be aware of? *

Household / Adult Primary Contact

Relationship to Participants: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Email Address *

Phone

Alternate Phone

Registration *

Winter Session (8 weeks): $128

Sibling Registration *

Winter session (8 weeks) for two children: $236 a $20 discount

Sibling Registration *

Winter Session (8 weeks) for three children: $344, a $40 discount

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Emergency Medical Consent: *

In the event of an emergency requiring medical attention for my child, I understand that PALS Chess instructors will make every effort to contact me. However, if I cannot be reached, I give permission for a licensed physician or medical treatment center to administer emergency medical care if needed.