Chess Club:____________________________Teacher:____________________________

Name:___________________________________________________________________________________

Grade:__________ DOB___________

Home address:_____________________________________________________________

_________________________________________________________________________

Home phone________________

email address_________________________________________________

Mother_____________________________________________________________________________

Cell phone_____________________________________

Father_______________________________________________________________________________

Cell phone_____________________________________

Allergies or other issues:_____________________________________________________

_________________________________________________________________________________________

How long has your son/daughter played chess?__________________________________

Has he/she played in any tournaments other than at school? __________If so, what was his/her last event?______________________________________________________

Does he/she have an OSCF rating?________________

Is he/she interested in playing in tournaments?__________________________________

Notes:___________________________________________________________________________________

_________________________________________________________________________________________

Medical and Photography Consent and Release of Liability

In consideration of participation in this Chess Odyssey event, participants acknowledge that they are aware of the nature of the activity, and that there are inherent risks in any such activity, and release Chess Odyssey and the hosting orgamization from any and all claims for personal injuries. Participants and/or parent/guardian of a registered minor authorize em-ployees of Chess Odyssey to seek medical treatment in the event of an accident or emergency. Photos taken during pro-grams may be used for promotional purposes. Payment of the registration fee and participation in the program constitute acceptance of this liability, medical, and photography release.