Club Registration - Fall 2017
For students enrolling at Camas Ridge, Charlemagne, Edgewood, Edison & Roosevelt clubs
Please complete a separate form for each child that you register
Oak Hill & South Eugene students register at their schools' offices
Student's First Name
Your answer
Student's Last Name
Your answer
Student's School
Your answer
Student's Grade in Fall of 2017
Which Chess Club Will Your Child Attend?
(Fees differ according to the number of sessions offered & expenses incurred)
Required
First Parent
(First and last names)
Your answer
First Parent's Email Address
Your answer
First Parent's Mobile Phone #
(If no mobile phone, please list home/work phone #)
Your answer
Second Parent
(First and last names)
Your answer
Second Parent's Email Address
Your answer
Second Parent's Mobile Phone #
(If no mobile phone, please list home/work phone #)
Your answer
Student's Known Allergies or Health Issues
(If so, please explain)
Your answer
Liability Waiver
By checking this box, I acknowledge that, to the best of my knowledge, my child is in good physical condition and fully able to participate in this course. I hereby elect for my child to voluntarily participate in said event. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me or my child or loss or damage to property owned by me, as a result of participation in this course. I also agree that, should my child suffer serious injury or illness and I or my spouse is not immediately available to direct the course of action, representatives of Southside Chess, LLC have my permission to seek medical attention for my child from a qualified physician, emergency medical technician or other qualified health professional.
Required
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