EVES Chess Club Registration Form 2011 2012

DIRECTIONS: 1. Please complete the entire form and print neatly incomplete forms will not be accepted and the student will not be registered. 2. Please read the details outlined in EVES Chess Club Flyer at http://www.eagleviewpta.com/programs.html#clubs before filling up this form. 3. Send in a separate form and separate check for each child. Make checks payable to EVES PTA Chess Club. 4. Enclose form(s) and checks(s) in a sealed envelope labeled EVES Chess Club Registration. For the Registration Deadlines, see the EVES Chess Club Flyer at http://www.eagleviewpta.com/programs.html#clubs. 5. Additional copies of this form can be obtained from the EVES office or downloaded from http://www.eagleviewpta.com/programs.html#clubs. CHECKLIST FOR REGISTRATION: Registration Form (required) Payment (required) Parental Waiver and Consent (required) Emergency Care Form (required) Volunteer Registration Form (required only if parent wants to volunteer) Scholarship Eligibility Documents (required only if parent wants to apply for scholarship)

I would like to register my child for (choose one or more):

Session 1

Session 2

Session 3

All three Sessions

Students Name: ___________________________________________________________________________ Teacher: ___________________________ Grade: ___________ Parents/Guardians Name(s): ______________________________________________________________________________________________________________________ Address: _______________________________________________________________________________________________________________________________________ Day time Phone 1: _____________________________________________________ Day time Phone 2: __________________________________________________________ Email: _________________________________________________________________________________________________________________________________________ Emergency Contact Name: ________________________________________________________________ Phone: _________________________________________________ Choose one of the options indicating Dismissal method: Choose one of the options indicating Scholarship eligibility: Picked up by parent OR Scholarship Eligible OR Child dismissed to SACC NOT Scholarship Eligible

I am interested in volunteering and I have submitted the Volunteer Registration Form indicating my preferences.

PARENTAL WAIVER AND CONSENT Whereas, the Eagle View Elementary Parent Teacher Association (PTA), as a service to its members and students, provides Chess Club instruction and associated activities for the students at Eagle View Elementary School (EVES); Whereas, the undersigned parent or legal guardian of the below named child/children, wishes to take advantage of the Chess Club program at EVES; In consideration for these services, the undersigned parent or legal guardian agrees and represents as follows: I am the parent or legal guardian of the below named child. I hereby agree to follow all registration requirements as outlined in the EVES Chess Club Flyer at http://www.eagleviewpta.com/programs.html#clubs. I hereby certify that my child is fully capable of participating in the designated activity and that I agree to provide my child and the PTA complete support, as required by the PTA, in case the PTA informs me of any reasons that are restricting my childs full participation in the Chess Club. I agree, in taking advantage of this after school activity, to release and hold harmless the PTA, including its officers, agents, members and volunteers; EVES, including its officers, agents, and employees; and any person or persons in charge of running the Chess Club program (the Chess Club coordinator), from any and all claims, demands, suits, costs (including attorneys' fees and litigation costs) and charges, in connection with or arising out of the provided after school program, including but not limited to bodily harm or injury to my child/children. I understand that this release includes any claims based on negligence, action, or inaction of the PTA, EVES and Chess Club coordinator. In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the Chess Club coordinator or other adult present to seek immediate medical care at any facility that this person deems most suitable. I further give my consent for any and all emergency medical treatment for my child when the child is in this individual's care. I have read this release and further agree that no oral representations, statements, or inducement apart from the foregoing waiver and consent have been made: Chess Club Session Number: _________________________________________________ Start Date: ___________________________________________________________ Childs Name: ________________________________________________________ Parent/Guardians Name: ____________________________________________________ Signature of Parent/Guardian: __________________________________________________________________________ Date: _____________________________________