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: _________________________________