e4 Summer Chess Camp Registration

Parent / Guardian Information
Primary Parent / Guardian Full Name

First NameLast Name
Primary Parent / Guardian Email
example@example.com
Primary Parent / Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Parent / Guardian Full Name (if applicable)

First NameLast Name
Secondary Parent / Guardian Email (if applicable)
example@example.com
Secondary Parent / Guardian Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Other Authorized Individuals to Pick Up Your Camper
How did you hear about e4 Chess Camp?

Emergency / Medical Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship to Camper
Any medical conditions or allergies we should be aware of?
Any emotional / behavior issues we should be aware of, or anything else we should know about your child?
Primary Doctor Full Name

First NameLast Name
Primary Doctor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Hospital

e4 Chess Camp Registration