CompanyThis field is for validation purposes and should be left unchanged. Brock's Gap Intermediate School Fall Chess Class Caesar Chess, LLC Caesar Lawrence – Director/Coach September 8, 2022 - December 15, 2022 PLACE/SITE Brock's Gap Intermediate School 730 Lake Cyrus Club Dr Hoover, AL 35244 Child's Name: First Last Age:Grade:Gender: Male Female Mom's Name: First Last Phone #:Cell #:Work #:Dad's Name: First Last Phone #:Cell #:Work #:Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Parent's Email: *Email used for Caesar Chess purposes only.**Other Relatives and/or Friends who can pick up your child from the Caesar Chess Class:Pickup Person Name 1: First Last Phone #:Cell #:Relationship:<>Pickup Person Name 2: First Last Phone #:Cell #:Relationship:PARENTAL CONSENT(Required) Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement.I, the minor’s parent and/or legal guardian, understand the nature of chess activities and events, and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activities. I hereby Release, Discharge, and Covenant not to sue Caesar Chess, its instructors, agents, volunteers, contractors, and other participants, any sponsors, advertisers, local, state and national affiliated organizations, and, if applicable, owners, lessors and/or custodians of premises on which the activities takes place (each considered one of the “RELEASES” herein). I AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the RELEASES from all liability, claims, demands, losses, damages, or costs, on my account caused or alleged to be caused in whole or in part by the Releases, which may arise in any manner or form from my child’s participation in this program. I also consent to allow my child’s photo to be used in promotion and advertising materials of Caesar Chess.Printed Name of Parent and/or Legal Guardian:Date:Signature of Parent and/or Legal Guardian:AUG 2022 Δ FLYER UPCOMING EVENTS December 20, 2025 08:00 Birmingham 2025 Magic City Classic December 20, 2025 08:00 Birmingham 2025 Pushing Pawns Scholastic December 13, 2025 08:00 Montgomery Bruising Bishops Scholastic
