Providence Academy-After-School Programs

2014-2015 School Year - Programs Beginning in Fall 2014

REGISTRATION DEADLINE IS FRIDAY, SEPTEMBER 19, 2014.

Attached is the registration packet Chess ClubK-8 After-School Program beginning September 22, 2014 2014. Please note that the registration deadline is Friday, September 19, 2014 for this program.

Registration Procedures:

Complete attached registration form/waiver.

Complete the attached permission slip.

Send in payment for Chess Club$100.00(checks payable to: Lenny McDougal).

Turn in forms and payment no later than Friday, September 19, 2014.

Chess Club (Grades K –8):

Mondays 3:05-4:00 K-5, 4:00-5:00 6-8

September 22-November 17

Instructor: Mr. Lenwood McDougal

The Chess Club will provide instruction in mechanics, strategy and tactics as well as provide opportunities for children to play other club members in a positive environment. Theobjective of the class is to teach kids the fundamental aspects of the game of chess. The mission of the program is to increase self-esteem, help kids to become critical thinkers and help them with problem solving.

Registration is limited to 16 students.

Minimum of 8 students is required.

There is a registration fee of $100 per child.

Questions? Feel free to contact Anna Offman, Office Staff 571-252-9259

REGISTRATION FORM/WAIVER

Please register my child(ren) for Chess Club

Parent(s) Name(s) ______

Phone (H) ______Phone (C) ______

Email ______

PLEASE COMPLETE FOR ALL PROGRAMS: As parent/guardian of the above student, I certify that he/she is in excellent health and has no physical, mental or emotional problems which are likely to prevent participation. I understand that this is an after school program and that there is no medical officer available and that the school does not provide any medical payments coverage (insurance). I am allowing my child to participate in this event at his/her own risk. By my signature below, I ______(my printed name), agree to pay for any medical expenses incurred by my child ______(my child’s printed name) as a result of participating in this this activity and will not hold the Instructor, or the staff liable for any reason related to my child’s participation in the program. I also give permission for my child to receive medical treatment, first aid, emergency medical care, and all other medical or surgical deemed reasonably necessary to my child’s health and well-being in case of accident, injury, or serious illness during participation in the above-referenced program/activities and understand that I, or my insurance, will be responsible on a primary basis for any medical bills incurred.

Parent/Guardian Signature: ______Date: ______

Permission Slip

My child, ______, has permission to stay for Chess Club on Mondays from September 22-November 17, 2014

Only those specifically named below will be allowed to pick up my child:

_____ I authorize my child to be picked up by:

Name: ______Relationship:______Phone: ______

Name: ______Relationship______Phone: ______

Students registered for after-school programs are expected to stay after school for these programs UNLESS a parent or guardian sends in a written note to school advising the school staff that the student will not be staying for the program.

In the event that the activity is cancelled due to weather or any other event the parents will be contacted.