Medical Office Registration Form s5

BAE CHESS CLUB Meetings are weekly, before school. Open to beginners and experienced players alike. Learn about a fun and fascinating game and of course, play chess!

My name is Daniel Zimmer, and I’m looking forward to coaching the next 13-week session of the Blue Chess Club. I have a deep passion for the game of chess, and I’ve played with and learned from some of the best chess players in the country, including John Miller (the previous coach) and International Master Leonid Bass. You can see my USCF information under the I.D. number 15332953 on www.uschess.org. I consider it a privilege to teach and coach your child in chess!!

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Today’s date: STUDENT INFORMATION Student’s Last name: First: M.I: Guardian’s last name: First: M.I:

Email:

Birth date: Age: Chess Experience or USCF ID # / / Street address: Home phone no.: Cell phone no.: ( ) ( ) City: State: ZIP Code: T-Shirt Size: Grade:

IN CASE OF EMERGENCY Last name: First: M.I: Home phone no.: Cell phone no.: ( ) ( )

Allergies/any other needed info: 1. Tuition cost to attend the program is $130. The program starts on January 17, 2017 and lasts 13 weeks. There is no club during the week of the spring break.

2. Enrollment in the chess program means committing to all 13 weeks. Parents who wish to withdraw their children after the first class will be charged for the entire program.

3. We will meet on Tuesday mornings from 8:05 to 9:00 AM. If school is canceled or delayed, chess classes will be canceled. A make-up day will be re-scheduled at the end of the session and parents will be notified.

4. For the students’ safety, parents must follow the safety procedures for the school. Note: Blue Ash Elementary School and the Blue Ash PTO are not responsible for students before class time.

5. All the students from grades 1-4 can enroll in the chess club.

6. Students who do not follow appropriate school behavior guidelines may be dismissed from the program. Refunds will not be given.

7. Food allergies or other medical conditions should be noted on the registration form.

8. Parents may attend classes and observe the material their child is learning. We have an open-door policy and always welcome parent involvement and feedback.

9. Payment can be made by check or money order to: BAE Chess club

4112 Locust Lane Blue Ash OH 45242

10. There are 14 spots available and they will be filled on a first come first serve basis. Receipt of payment will be the criterion for the allocation of a slot.

11. Any questions please e-mail Eric Simon Thomas at [email protected]