PALS Chess Club - Spring 2023 Session

Ralph Moody Elementary

Chess Club Registration Form

Day and Time: Wednesdays after school from 2:45-3:45 p.m in room 175

Spring Session: 1/25, 2/1, 2/8, 2/15, 2/22, 3/1, 3/15, 3/22, 4/5, 4/12, 4/19, 4/26

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

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 following chess club.

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

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 *

Spring Session: $192

Sibling Registration *

Spring Session for two students: $384

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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.