PALS Chess Club - Fall Session 2023

Lois Lenski Elementary

Chess Club Registration Form

Day and Time: Mondays after schools from 2:45-3:45

Spring Session: 9/11, 9/18, 9/25, 10/2, 10/9, 10/30, 11/6, 11/13, 11/27, 12/4, 12/11

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 following 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 *

Fall session (11 weeks): $198

Sibling Registration *

Fall session (11 weeks) for two children: $396

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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.