PTG Chess Club Registration Form

Day/Time: September 27th-November 22nd, Fridays 3:30-4:30 pm Program Grade: Grades 1-4 Program Fee: $50 (includes Team T-Shirt) Checks payable to: Moses DeWitt PTG (A PTG Funded Financial Hardship Scholarship is available. To apply, please contact PTG Treasurer, Sue Smith at smeehan@twcny.rr.com or 214-5922) Childs Name: ______________________________________________ Parents Names: ____________________________________________ Grade: _______________________ Teacher: ___________________ Home Phone: ____________ Work: ___________ Cell: ______________ In case of emergency and I cannot be reached, please contact: Name: _______________________ Phone No. ____________________ Allergies: _________________________________________________ Please list all adults who may pick up your child (proper photo ID required) _________________________________________________________ _________________________________________________________ _________________________________________________________ Only those people listed above will be able to pick up your child. Your child must be picked up from the PTG sanctioned program or event at the activity site and by the designated time the program ends. There will be no exceptions to this policy. PLEASE BE KIND AND BE ON TIME! If your child will not be attending a class for whatever reason, please send in a note. This is to ensure that your childs whereabouts are known for safety reasons. There will be no refund of registration fees once classes have begun, so please make sure your child wants to participate in the program. I have received a copy of the Code of Conduct and the Late Pick-Up Policy Form. I understand if these rules are broken, my child will be excused from class for the rest of the year and forfeit the class fee. Your signature below acknowledges your understanding of the rules and regulations for after-school activities sponsored by the PTG. Student Signature: ______________________________ Date:________ Parent Signature: _______________________________ Date:________