JCPS Chess Academy Registration Form
This form is to be completed by the parent or guardian of the interested JCPS student
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Student Name (First) *
Student Name ( Last ) *
Student Current School *
Student Current Grade *
Parent | Guardian Name ( First & Last ) *
Parent | Guardian Email  *
Parent | Guardian Phone Number  *
Street Address *
City, State *
Zip Code *
Emergency Contact
in the event a parent or guardian of participant cannot be reached, this emergency contact is the next person to be contacted on behalf of the participant (jcps student)
 *
Jefferson County Public Schools also reserves the right to remove participants from the program if they present a threat to the children or if they abuse the privilege of the mission statement of Jefferson County Public Schools. I hereby grant permission to the Jefferson County Public Schools to take my child’s photo while participating in the activities to use for publicity.
By filling in your name below, you acknowledge that JCPS accepts this entry as a formal (electronic) signature.
Full Name (First & Last) *
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