Registration Form - Chess Castle Chess Camp 2016 MNCHESSCAMP@GMAIL.COM

Session Three sessions are All Day Mon-Thurs (9am-4pm) Cost: $200/session
Check mark or fill in

Session 1 June 20-23 ________ Payment in cash/check at on-site

Session 2 July 4-7 ________ Checks Payable to Chess Castle

Session 3 August 1-4 _________ No refunds once child has been enrolled
Payment type

Cash ___________ Check____________ Paid__________ (for chess coordinator use)

PLEASE PRINT LEGIBLY

Child’s Name_________________________ _______ ______________________________

First M. Initial Last

Birthdate ______________ Age:______ Grade:_____

mm/dd/yyyy

Child’s Name_________________________ _______ ______________________________

First M. Initial Last

Birthdate ______________ Age:______ Grade:_____

Child’s Name_________________________ _______ ______________________________

First M. Initial Last

Birthdate ______________ Age:______ Grade:_____

List any medical conditions, disabilities, or food allergies we should be aware of:

This can include, if they are vegetarian, or allergic to peanut butter, etc.

Parent 1 Name ____________________________ Day phone (_______) _______________

Parent 2 Name ____________________________ Day phone (_______) _______________

Street Address ______________________________________________________________________

City ________________________________________ State ________ Zip _______________

Home phone ( ______ ) _______________ E-Mail Address___________________________

I give permission for my child, (Initials)__________________________________, to participate in any recreational activities such as frisbee, football, soccer, playground use, and any other outdoor activities.

I give permission for my child, (Initials________________________________________, to have pictures or video taken at camp that may appear on our website or flyers.

Parent Signature_________________________________________ Date _____________________

1

Chess Castle located 1121 Jackson St NE Minneapolis MN, 55413

Next to Broadway and Central

More info at our website Mplschess.weebly.com

Tremayne Talbot

2016-03-08

TREMAYNE

Microsoft