Student Enrollment Form
Students Personal Information
Students Legal Name (Surname, First Name, MI) *
Your answer
Students Preferred/Nickname *
Your answer
Students Date of Birth *
MM
/
DD
/
YYYY
Students Gender *
Name of School attending
Your answer
Rising Grade *
Your answer
Student common mental, physical, emotional challenges (if present) *
Your answer
Medical Concerns including but not limited to allergies *
Your answer
Parent/Guardian Information
First Last Name of Guardian & Relationship (Mother, Father, etc.) *
Your answer
Contact Information
Please also note preferred way to be contacted
Email *
Your answer
Home/Work Phone *
Your answer
Cell Phone *
Your answer
Student/Parent/Guardian Goals *
Please describe what benefits you're hoping to receive from lessons.
Your answer
Photo Release Form Legacy Chess Academy Permission to Use Photograph & Recordings...... I grant to Legacy Chess Academy, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Legacy Chess Academy, its assigns and transference to copyright, use and publish the same in print and/or electronically. I agree that Legacy Chess Academy, may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web Content. I have read and understand the above: *
Refund, Cancellation & Payment Policy:: Is it understood by the applicant of this form that a 48hrs Notice for Cancellations is required. And to expect a 5% increase on invoice for any past due fees. No refunds are to be expected. *
An Invoice will be emailed to the address you provided. Any additional Concerns/Questions? *
Information, comments, questions
Your answer
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