25-29 June 2018
Texas Tech University
US/Central timezone
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Registration Form

Please, note that fields marked with * are mandatory


Parent/Guardian Information
 
First Name: *
Last Name: *
Home Address: *
City: *
State: *
Zip Code: *
Phone Number: *
555-555-5555
Email Address: *

General Information
 

Full Day: 9:00 a.m. - 4:00 p.m. (Lunch Included)

Half-Day: 1:00 p.m. - 4:00 p.m. (Lunch NOT Included)


Participant Information
 
Participant 1

Camp Registration Fees

*

Personal Information

First Name: *
Last Name: *
Home Address:
Note: Only needed if different than the parent address.
City:
State:
Zip Code:
School currently attending: *
DOB: *
 MM/DD/YYYY
Gender *
USCF Rating:
Note: This is not mandatory.
USCF ID#:
Note: This is not mandatory.
T-Shirt Size: *
Special Concerns:

Participant 2 *
Select "YES" if a second child is participating. Enter his/her information below. All fields are mandatory unless otherwise noted.

Camp Registration Fees

*Sibling price included.

Personal Information

First Name:
Last Name:
Home Address:
Note: Only needed if different than the parent address.
City:
State:
Zip Code:
School currently attending:
DOB:
 MM/DD/YYYY
Gender:
USCF Rating:
Note: This is not mandatory.
USCF ID#:
Note: This is not mandatory.
T-Shirt Size:
Special Concerns:

Participant 3 *
Select "YES" if a third child is participating. Enter his/her information below. All fields are mandatory unless otherwise noted.

Camp Registration Fees

*Sibling price included.

Personal Information

First Name:
Last Name:
Home Address:
Note: Only needed if different than the parent address.
City:
State:
Zip Code:
School currently attending:
DOB:
 MM/DD/YYYY
Gender:
USCF Rating:
Note: This is not mandatory.
USCF ID#:
Note: This is not mandatory.
T-Shirt Size:
Special Concerns:

Drop-Off Fees
 

The fee for early drop off and late pick up is $5.00 per child per drop-off/pick up. If you will be dropping off your child(ren) early or picking up your child(ren) late please indicate below.

A.M Drop-Off (8 A.M)

*
   Monday   5.00 USDTotal: 0 USD
*
   Tuesday   5.00 USDTotal: 0 USD
*
   Wednesday   5.00 USDTotal: 0 USD
*
   Thursday   5.00 USDTotal: 0 USD
*
   Friday   5.00 USDTotal: 0 USD

P.M. Drop-Off (5 P.M.)

*
   Monday   5.00 USDTotal: 0 USD
*
   Tuesday   5.00 USDTotal: 0 USD
*
   Wednesday   5.00 USDTotal: 0 USD
*
   Thursday   5.00 USDTotal: 0 USD
*
   Friday   5.00 USDTotal: 0 USD

Emergency Contact Information
 
First Name: *
Last Name: *
Cell Phone: *
555-555-5555
Home Phone: *
Work Phone: *

Media Coverage/Participation Form
 

I hereby give permission for the name of said Minor Child to be released to the media or for him/her to participate in any media coverage that might transpire during the course of the 2018 Summer Chess Camp. I authorize the use of the Minor Child's name, biography, likeness, voice and performance in the production of the program and for the purpose of publicizing and promoting the program.

I represent that I am a Parent, Managing Conservator, or Guardian of the Minor Child whose name is listed above, and I hereby agree to have my child participate in media coverage.

Signature of Parent, Managing Conservator, or Guardian: *
Today's Date: *
 MM/DD/YYYY
My child(ren) may participate in media coverage. *
Participant 1 - Name: *
Participant 2 - Name:
Participant 3 - Name: