..... Aspen Chess Club Membership Form .....

STUDENT INFORMATION
First Name (one name, no spaces)
Last Name
Date of Birth
Grade-School
Teacher (last name)

PARENT/GUARDIAN #1
First Name         Last Name
Email#1                Email#2
Cell        Home        Work
Enter at least 1 email and 1 phone number: format ###-###-####

PARENT/GUARDIAN #2
First Name         Last Name
Email#1                Email#2
Cell        Home        Work

MEDICAL INFORMATION
Doctor Name         Doctor Phone
List Allergies (leave blank if none)

List Other Medical Issues (leave blank if none)


CONTACT and PICKUP INFORMATION
Emergency Contact Name         Phone
Emergency Contact Name         Phone
Names of People My Child Can Leave Chess Club With (in addition to the above):

Simply put "self" above if child is allowed to leave or go home on their own

Emergency Medical Waiver: If your child is seriously injured or becomes seriously ill during chess club (including outdoor recess) we will attempt to immediately contact you and the emergency contact(s) you provided. In an emergency, an adult helper, coach or other organizer is authorized to act as they believe circumstances warrant, including performing first aid and/or arranging for transportation to the Los Alamos Medical Center. It is understood that the parent/guardian is responsible for all costs incurred due to this incident and all follow up medical care. I further recognize that the Aspen Chess Club carries no insurance and I hereby release all volunteers, instructors, teachers, and organizers of the Chess Club from any and all liability, claims, and demands that may arise from participation in the Aspen Chess Club.
I am this child's legal parent/guardian and I've read and accept the medical waiver.

Photo/press release: Photographs may be taken of your child during the Chess Club for the Los Alamos Monitor, year book, and other publicity. In addition, tournament results may be published online or in the papers throughout the year. No checkmark will be treated as yes.
yes no  ---  It is ok for my child's picture and/or name to be used in news pertaining to chess club

MAPS Score Study: Coach Dave is interested in studying the benefit that playing chess has on kids. One way to do this is follow the relative improvements of chess club kids standardized test scores versus the norm. Principal Vandenkieboom has said this would be ok as long as the child's parents permitted. Coach Dave will treat the information as confidential and names will not be mentioned in any reported findings. No checkmark will be treated as yes.
yes no  ---  It is ok for Dave Poston to view the history of my child's MAPS scores.

Rules and Expectations: The remarkable success of the Aspen Chess club has made the club very large. As such, it is very hard to maintain a productive environment if any child either displays or instigates disruptive behavior. Chess Club is a volunteer-run organization, and retains the right to exlude any child from chess club (which unfortunately has been done several times). Please ensure that you and your child read the rules and expectaions, that your child agrees to abide by these rules, and that he/she knows they can be removed from the chess club if they don't follow the rules.
My child and I understand and agree to abide by Chess Club rules and expectations.


The chess club cannot exist if parents do not volunteer. Please use the link on the website to volunteer. Also, if you can, please make the requested membership fee donation, so we can buy the supplies needed, learning materials, club awards, tournament fees, etc.

..... Ready to Submit .....

Note: if you are entering more than 1 child into chess club, you can simply hit the back button on your browser after you submit and change the necessary information and then submit again. Next year you will be able to retreive the old information when applying for another year.



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