Child's Name:
Boy: Girl: Date of Birth (mm/dd/yy):

Camper's USCF Rating:

Parent Name:
Home Phone# Work Phone#
Email Address:
Address:
City: State: Zip Code:


Fee Schedule:

$189.00 per week - Due with Enrollment

Chess Camp times are 9am - 3pm

Dec 19 – Dec 23, 2011




Purchase a T-Shirt:
(T-Shirts will be waiting for you at the Camp)

Size of First T-Shirt (Additional $18): Select Small Medium Large X Large XX Large

Size of Second T-Shirt (Additional $18): Select Small Medium Large X Large XX Large

Payment Method:
Visa Mastercard Discover
Credit card number: Exp (mm/yy):
Three Digit Code on the Signature Panel on the back of the card:
NAME (as it appears on credit card):


I approve this application and certify the applicant(s) capable of such an experience. I grant permission for the applicant to participate in all camp activities understanding that competent leadership will be provided. In case of accident the camp is authorized to secure emergency medical treatment. The camp is not responsible for lost, stolen or damaged personal articles. I authorize the camp to have and use photographs, slides and video tapes of the person(s) names on this application.