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New Student Registration

STUDENT INFORMATION *required
Name *
Name
Date of Birth *
Date of Birth
Please list any prior chess experience
PARENT 1 *required
Name *
Name
Phone *
Phone
Address *
Address
PARENT 2 - not required
Name
Phone
Phone
Address
Address
Caregiver - not required
Name
Name
Name
Phone
Phone
Monthly Autopay - not required
For added convenience we can charge your credit card at the end of each month for any outstanding charges on your account.
Name on Card
Name on Card
Expiration date
Expiration date