TEANECK REGISTRATION FORM
Child #1
Firs Name
Last Name
DOB
Child #2
Firs Name
Last Name
DOB
School
Grade(s)
Mother's Name
Business phone #
Father's Name
Business phone #
Address
Line 1
Line 2
City
State
Zip
E-mail
Home phone#

Day Of Class: (please circle)
MONDAY WEDNESDAY SUNDAY

Level of Class (please circle):
BEGINNER ADVANCED BEGINNER INTERMEDIATE 1 INTERMEDIATE 2 ADVANCED

TIME (please circle):
4:00 PM 5:15 PM 6:30 PM 7:30 PM 10:00 AM 11:15 AM 12:30 PM

Tuition (please circle): 1 hour/week 1.5 hour/week 2 hours/week 3 hours/week MASTER CLASS (10 classes) 2hrs MASTER CLASS (10 classes) 1hr
1st child $253 $374 $440 $550 $550 $350
2nd child $210 $300 $365 $410
Tuition is based on 11 classes
Please Add $55 registration fee if registering after FEBRUARY 20.

MAKE YOUR CHECK PAYABLE TO:INTERNATIONAL CHESS ACADEMY
Mail to the address:
Diana Tulman 28 Canterbury Lane New Milford NJ 07646