Child Information Record

CHESS CLASS TIMES AND LOCATIONS

Alabaster City Schools

Hoover City Schools

Pelham City Schools

Shelby County Schools

Alabaster City Schools

Hoover City Schools

Pelham City Schools

Shelby County Schools

** Classes start after Labor Day. Ten (10+) students needed for chess class to make! **
~ The chess class fee is $200/Fall 2023 Semester & $250/Spring 2024 Semester. ~

CHILD INFORMATION RECORD

Name(Required)

First Middle Last

Hidden

Date of Admission

Grade(Required)

PERSONAL INFORMATION

Home Address

Street Address City State Zip

School(Required)

PRIMARY ACCOUNT HOLDER

Name

First Last

Home Address

Street Address City State Zip

Cell Phone

Work Phone

Home Phone

Employer Name

MEDICAL INFORMATION

Physician's Name

Physician's Phone

Preferred Hospital

Allergies and/or Special Diet

Medical Conditions

Special Needs and/or Physical Restrictions

Anything else that you would like for us to know about your child

Will your child require medication (emergency, as-needed, or scheduled) for use in After School Care or Summer Camp?

OTHER INFORMATION

Transportation Mode

EMERGENCY CONTACT & RELEASE OF CHILD

List of all individuals, including parents/ legal guardians, in order of preference, to be contacted in an emergency.

EMERGENCY

Name

Cell

Work

Home

RELEASE OF CHILD ONLY

List of all individuals, other than the parents/ legal guardians, to whom the child may be released.

RELEASE

Name

Cell

Work

Home

Phone

This field is for validation purposes and should be left unchanged.

CHESS CLASS TIMES AND LOCATIONS

CHILD INFORMATION RECORD

PERSONAL INFORMATION

PRIMARY ACCOUNT HOLDER

MEDICAL INFORMATION

OTHER INFORMATION

EMERGENCY CONTACT & RELEASE OF CHILD

RELEASE OF CHILD ONLY

10+ registered students are required for a class to be confirmed Coach Caesar will send Confirmation via email

10+ registered students are required for a class to be confirmed
Coach Caesar will send Confirmation via email