Student's Name

Student's Age

Student's Email (or Parent's Email if student is a minor)

Parent/Guardian Name

Phone number

Program I'm interested in:
—Please choose an option—ClassesPrivate LessonsSummer Program

How did you hear about us?
—Please choose an option—Web searchEmailFriend/FamilySchoolOther

On a scale of 1 to 10, what is your (or your child's) interest in chess?

What have been the student's barriers to success with chess?

How much chess experience do you (or your child) have?

Our chess community is wildly important to us. Do you agree that you and your child will be respectful members and contribute to the integrity of the game and our Academy?

What impact would you like to see chess have on you (or your child)?