Registration Form — Bright Minds RVA Chess Club

(Students must be aged 13-17 to participate in this Chess Training and Tournament).

For more information call: (804) 814-4434

Bright Minds RVA - Registration Form

Enrollee's Name

First Name

Last Name

Male

Female

School

Grade

Age

Do you possess a computer?

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

Mobile

Parent/Guardian Consent

Parent/Guardian's Name

First Name

Last Name

Address

(If different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

Does your child have any allergies or medical conditions?

Yes

If Yes, please describe:

I give permission for (child's name) to join the Bright Minds Chess Club.

I approve my child being filmed during the chess classes and/or tournament. I agree to provide transportation for my child. I agree to hold harmless, the chess instructors, sponsors, donors, coordinators, volunteers and others affiliated for any accidents or injuries my child endures.

Agree

Signature:

My signature below indicates that I have read, understand and agree to all information in this Registration Application.

Relationship to Child

Date

YYYY

Info

Action