Special Programs

Media Release Form*
Please use one form per Child *
Chess Club may develop, participate in, or be the subject of media-based presentations and events which highlight various chess and educational activities that take place during the course of the year. These presentations/events are of two types. Those developed by Chess Club personnel and/or commercial enterprises. These may include but are not limited too - 1. Photographs of students and activities, Slide/tape presentations, Videotapes of students and activities, Computer generated presentations which may incorporate scanned photographs and video clips Computer based productions transmitted via telecommunications 2. These media based presentations may be used in Faculty in-services, Parent programs, Staff development activities, Media festivals (local, state and international), Public relations, Newspaper articles, TV presentations, Chess Club approved Internet web pages and Blogs.
- I hereby GIVE my permission to Chess Club to publish my child’s photo-graph and identification in as well as to publish my child’s presentation (as listed above) in any of Chess Club’s media-based productions for the above stated purposes
- I hereby DENY my permission to Chess Club to publish my child’s photo-graph and identification in as well as to publish my child’s presentation (as listed above) in any of Chess Club’s media-based productions for the above stated purposes.
Your Chess Goals*

Available timings*
- Eastern
- Central
- Mountain
- Pacific
GROUP / PRIVATE STUDENTS - Please Choose from Below **
Liability Release I, the undersigned, in consideration of participation in the programs offered by ChessKidsNation agree to indemnify and release the After school, summer classes, Online and Group Classes, its officers, staff and employees, from any and all liabilities from any injuries which may be suffered by the above named child, arising out of, or in any way connected with participation in the classes or activities offered by the program. I acknowledge that I have read the above agreement and release, and fully understand that I have assumed all the risks of injury that may occur in the activities offered by the program. I hereby further authorize the program as the agent for the above named child to consent to any medical diagnosis or treatment and hospital care rendered by and under the general supervision and advice of a licensed physician or surgeon in case of accident or illness during a session of any classes or activities offered by the program. *
Date
Liability Release signed by (Please print your name) **
Registration fee
Price: $1.00
Coupon
Total
$0.00