PALS Chess Club - Fall Session

Holm Elementary School

Chess Club Registration Form

Day and Time: Fridays after school from 2:30 - 3:30

Fall Session: 9/16, 9/23, 10/7, 10/21 10/28, 11/4, 11/11, 11/18, 12/2, 12/9, 12/16

Open to grades K-5: After each weekly lesson, students will be paired according to age and level.

Participant Information

First Name *

Last Name *

Student's Birthday * 🛈 +

Grade *

Level of Experience *

Register a second child?

Yes

First Name

Last Name

Student's Birthday 🛈 +

Grade

Level of Experience

Does your child need to return to the school's aftercare program following chess club? *

Yes, please take my child to the school's aftercare program following chess club.

No, my child will be picked up by a designated adult following chess club.

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 *

Fall Session: $132

Sibling Registration *

Fall Session for two students: $264

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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.