Internet Lessons | Mountain Lake Chess Club

Number of Students:

First Student Name:*

First Student Gender:

Boy
Girl

First Student Birthday (xx/xx/xxxx):

First Student Grade:

Second Student Name:*

Second Student Gender:

Boy
Girl

Second Student Birthday (xx/xx/xxxx):

Second Student Grade:

Third Student Name:*

Third Student Gender:

Boy
Girl

Third Student Birthday (xx/xx/xxxx):

Third Student Grade:

Fourth Student Name:*

Fourth Student Gender:

Boy
Girl

Fourth Student Birthday (xx/xx/xxxx):

Fourth Student Grade:

Fifth Student Name:*

Fifth Student Gender:

Boy
Girl

Fifth Student Birthday (xx/xx/xxxx):

Fifth Student Grade:

Parent Details:

Parent's Name:*

First Last

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone:*

Your Email:*

Purchase a T-Shirt

(T-Shirts will be waiting for you at first lesson)

T-Shirt Quantity:

T Shirt Price:

Size of First T-Shirt (additional $18):

Size of Second T-Shirt (additional $18):

Size of Third T-Shirt (additional $18):

Size of Fourth T-Shirt (additional $18):

Size of Fifth T-Shirt (additional $18):

Payment Details:

Total

$0.00

Payment Details:*

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Note:

I approve this application and certify the applicant(s) capable of such an experience. I grant permission for the applicant to participate in all camp activities understanding that competent leadership will be provided. In case of accident the camp is authorized to secure emergency medical treatment. The camp is not responsible for lost, stolen or damaged personal articles. I authorize the camp to have and use photographs, slides and video tapes of the person(s) names on this application.