^{Yes, please sign me up for chess club - Fall 2010.}

 Include payment of $126 for the full 14-class schedule or $60 for the first six classes.

Make checks payable to the Sioux Empire Chess Foundation or  S.E.C.F.                                                                                                                                   

Student’s Name: ____________________________________     Date of Birth: _______________

School & Grade:      _______________________________________________________________

Parent’s Name/s: __________________________________________________________________

Parent’s Signature: ___________________________

E-mail___________________________________________________________________________

Phone Numbers:___________________________________________________________________

Address: _______________________________City: _________________ State:_____   Zip:________