CHARLOTTE YOUTH CHESS CLUB

 REGISTRATION FORM -FALL 2007

STUDENT________________________________________________________  

SCHOOL:_________________________________ GRADE ________________  

ADDRESS ________________________________________________________  

_________________________________________________ZIP______________  

PARENT/GUARDIAN_________________________________________________________   

PHONE: ______________________  

EMAIL ADDRESS:______________________________________

PARENTS CAN BE REACHED AT: ________________________________DURING CLASSTIME 

SKILL LEVEL:  ___BEGINNER _____ INTERMEDIATE ____ ADVANCED 

PARENTS:   I UNDERSTAND THAT CYCC IS NOT REPSPONSIBLE FOR MY CHILD’S BEHAVIOR.  PARENTS ARE

 RESPONSIBLE FOR ANY DAMAGE TO SCHOOL PROPERTY OR PERSONAL PROPERTY.   

PARENTS SIGNATURE _________________________________________________________

ANY MEDICAL CONDITIONS OF CHILD:____YES ________  

NO____________________ EXPLAIN: __________________________________  

SEMESTER:   $200.00     (SIBLING $175.00 )  ___CHECK #  __________________ (MADE OUT TO:  CYCC)  

WEEKLY FEE OPTION:  $17.00 PER WEEK (15.50 SIBLING)

 BRING PAYMENT WITH THIS FORM FIRST DAY OF CLASS