Registration form

Participant’s Information:

Child’s First Name: _________________________________________

Last Name: _______________________________________________

Birth Date(d/m/y):____/_____/________ Age: _____ Gender: M F

School: _________________________________________

Grade:________

Chess & Math Association rating: __________________

Chess Federation of Canada rating: _______________

Emergency Contact:

Last Name: _____________________ First Name: _______________________

Home Address: _____________________________________________________________

Home Phone #: _________________________ Business Phone #:__________________

Email: ____________________________________________________________________

Allergies/Special Needs

My signature below indicates my permission to have my child_______________________________

Take part in “The Knights of Chess” Intense Reinforcement Course (child’s first and last name)

Although it is understood that the instructors will endeavor to provide the maximum supervision possible, “The Knights of Chess” will not be held responsible for injures and/or loss of property to my child.

Signature of Parent / Guardian: ____________________________________________

Date: _________________________________