2017-2018 Chess for Scholastic Success Enrollment Form

For details, please see your school's flier.

Please fill out this form completely (all yellow fields!) and carefully. You can enroll multiple students in one session. After clicking on "Add to Cart" you will be taken to the PayPal site. Simply click on "Continue Shopping" to return to this page to add more students. If you are entering multiple students from one household, you need enter common information like addresses, phone numbers, e-mails, etc., only once.

I will confirm your enrollment by e-mail.

Questions or problems? Contact Joe Riegsecker at joepye@pobox.com.

Student's Full Name

School

Please choose... Chamberlain Chandler GHS GMS Model Parkside Prairie View Waterford West Goshen Other

Grade

Please choose... 2 3 4 5 6 7 8 9 10 11 12

Parents' or Guardians' Names

Street, City, State, Zip

Phone Number(s) (include area code if not 574)

E-mail Address(es)

Fees

Please choose... Chess Club Only $15.00 USD Chess Club and T-shirt $25.00 USD T-Shirt Only $10.00 USD

T-shirt Size, if applicable.

Please choose... None Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra Large Adult Double Extra Large