Diplomat Chess

CHILD NAME

PARENT/GUARDIAN NAME 1

PARENT/GUARDIAN NAME 2

PHONE NUMBER 1

PHONE NUMBER 2

EMAIL

CHILD GRADE Select Grade K 1 2 3 4 5 6 7 8

CHILD'S TEACHER IN SCHOOL

IS THERE ANYTHING ELSE WE SHOULD KNOW? ALLERGIES, SPECIAL NEED, ETC.

PICKUP Select Pickup Parent Pickup Aftercare

Purchase tournament-style chess set (board, pieces and carrying case). Not required, all equipment provided during the club. Select Option No Yes (+$20)

Pingry School, Pottersville, p.m. only, 8/14, 8/21