Littlewood Registration 2023

Alachua County Scholastic Chess Association

Club Sign Up Form
CHESS CLUB RULES - Please make sure your child understands these rules and is truly interested in playing chess.
1. Children are expected to go immediately to chess club at the end of school 1:52pm (12:37pm on early Wednesdays) and check-in with ACSCA staff members. Children who go to EDEP must check-in there first!
2. During chess club children must exhibit an interest in learning chess and improving their game.
3. Every child will remain in chess club until 3:00pm (1:45pm Early Wednesdays) unless he or she is signed-out by a parent or designated adult. All children must be picked up promptly at 3:00pm (1:45pm EW). Consistent late pick-up will result in a late fee of 10.00$ for every 15 minutes after 3:00pm (1:45pm EW).
4. Inappropriate behavior, including foul or disrespectful language, may result in dismissal from the club.
STUDENT INFORMATION:
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Please Select K - 5
Name of School*
Does your child know how to play?*

YesNo
Does your child go to EDEP?*

YesNo
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name (1)*

First NameLast Name
Parent/Guardian Name (2)

First NameLast Name
Phone Number (1)*

Area CodePhone Number
Phone Number (2)

Area CodePhone Number
Address (This will be used to mail your child's USCF membership card)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Names of any other pick up persons other than the Parent/Guardian
E-mail*
We would like to include pictures of Chess Club on our website this year.

Optional Photography and Video Release

The ACSCA may, from time to time, document the activities of the Chess Club with photos or videos. I hereby assign and grant The ACSCA unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child. Including the use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.
Photography and Video Release Consent

I AgreeNo, Thank you
I have read and agree to the Club Rules stated above and that information provided is correct:
Signature*

Clear

Alachua County Scholastic Chess Association

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION:

Credit Card