Orchard Elementary Chess Club

(www.eagleschessclub.weebly.com)
3:30-4:30pm, W, beginning Nov. 6th

Participant/Parent Information & Waiver Forms

Emergency Contact and Player Information: The following information is provided to the Orchard Elementary Chess Club, for parental contact and emergency information. The information will be used for the chess club/team only and not for outside personal use. The coach and volunteer parents will be present at all meetings. Please fill out the information below to help coaches and volunteers see to the safety of your child. Student Name: ____________________________________ Grade/Teacher: ___________________________________ Mothers Name: __________________________________ Phone #: _______________________ Email: _________________________ Fathers Name: ___________________________________ Phone #: ______________________ Email: _________________________ Alternate Emergency Contact: _______________ Phone #: ____________________ Carpool Names (Please list the names of adults you authorize to drive your child home and/or if your child is a walker): _______________________________________________________________________

Parent/Guardian Waiver: I, the undersigned, am the parent/legal guardian of the youth whose name is listed below. I understand that the PTA is offering chess club with no fees to my child and that, if through fault of my child, damage or loss to the chess sets used occurs I will replace the set at a fee of $20. Having read this waiver I, and in behalf of my child, do waive and release the Orchard Elementary Chess Club, its officers, directors, and related personnel from all claims and liabilities of any kind arising from my childs participation in this program or related events. I further authorized the coach/program director to consent to and authorize any medical care or treatment for my child that may be reasonably necessary resulting to an emergency, accident or illness of the participant before, during and after practices or related events. I agree to the bearing of all related costs. I grant permission to all noted above to use photographs, videos, recordings or any other record of this program for any legitimate purpose. I also understand that I must provide transportation for my child at the end of the scheduled activity. This authorization and waiver will remain in effect for the duration of school year. Childs Name): _____________________________ Date: _________________

Parent/Guardians Name: ________________________ Date: __________________ Parent/Guardian Signature: ____________________________

Players Good Conduct Pledge: I, ___________________, will come to each meeting prepared to listen and learn. I promise to take care with our club chess sets and put them away properly before leaving. I will do my best and cheer other club members in their efforts to gain a new skill. Players Signature: _____________________________ Date: ________________

Please return the completed form to the team coach or front office.