SOUTHSIDE JUNIOR CHESS CLUB

MEMBERSHIP FORM

Membership for 12 months:		 $25.00
Nightly Fee: $5 (Members); $7 (Non-members)

Player Surname:	____________________________	Given Name:	_______________________

Parent's Names:	________________________________________________________________

Address:		________________________________________________________________

			____________________________		Postcode:  ____________________

Date of Birth:		____________________________		Male  /  Female

Email:			________________________________________________________________

Phone (Home):	____________________________	Mobile:    __________________________

School:		________________________________________________________________

Does the player have any medical condition we should know about – please specify:

__________________________________________________________________________________

__________________________________________________________________________________

Parent's Signature:	__________________________________	Date:  _____________________