Chess Enrichment Online Program Enrollment

First Trimester Starts on September 28, 2020. Information Secure: Student information is confidential and is not shared with others.

Select Your Program Session/s:*
- Chess Level 1 & 2 - Tuesdays (12 Sessions; $192))
- Chess Level 1 & 2 - Thursdays (11 Sessions; $176)
- Chess Level 3 & 4 - Mondays (12 Sessions; $288)
- Chess Level 3 & 4 - Wednesdays (13 Sessions; $312)
Student's Name*
First Last
Student's DOB*
Date Format: MM slash DD slash YYYY
Grade*
School*
Please list any health alerts we should be aware of.*
Phone*
Email*
Address*
Street Address City State ZIP Code
Photo Release Agreement:*
I hereby grant Chess Educators permission to use the likeness or any likeness of my child, to exhibit/publish in any/all of its publications, including websites, for the purpose of publicizing any/all Chess Educators educational activities or any other lawful purpose. We will not publish your child’s name or other protected information. I understand that any and all of these likenesses will become the property of Chess Educators. I hereby release Chess Educators, its governing body, employees, and representatives from any responsibility from all claims, demands, and causes of action which I, my heirs, representatives, executors, or any other person/s acting on my behalf or behalf of my estate have/may have by reason of this authorization.
- I agree
Parent/Guardian*
By submitting this form, I confirm that I am the parent or guardian of the student and am enrolling my child for this program.
First Last