GENERAL REGISTRATION FORM

(submit one for each participant)

To register, please fill the blanks

Name of the event / program to register:
Date(s) of the event / program:
How did you learn about this
event / program?:

PARTICIPANT INFORMATION

First Name: MI: Last Name:

USCF ID#:
Exp. Date:
USCF Rating:

Home Phone:
Work Phone:
Cell Phone:
E-Mail:

Address:
City:
State:
Zip:

Emergency Contact Name:
Emergency Phone:

Include any relevant information (ex. interest in mental challenge, chess experience, etc.) that could help us in making a favorable decision

ADDITIONAL INFORMATION FOR YOUTH REGISTRATION

Date of Birth:
Gender:   M F

School:
School City:
Grade:
GPA:

Father's Info: Mother's Info:
Name: Name:
E-Mail: E-Mail:
Work Phone: Work Phone:
Cell Phone: Cell Phone:

Participation Waiver and Release
I, as a participant or a parent/guardian of this participant, do hereby consent to his/her participation in the chess programs. In consideration of services being performed, I do hereby release the Vivacity, Inc., its officers, managers, organizers, agents, members, representatives, successors, assignees, coaches, referees, instructors and employees (collectively referred to as the �Company�), in their official and individual capacities, from any and all claims, liability or demands for any personal injury, sickness or death, as well as property damage expenses of any nature whatsoever which may be sustained or incurred by said registrant in connection with participation. The Company shall not be responsible for damaged, lost or stolen articles, inside and/or outside the facility. Furthermore, I, on behalf of the participant, hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of the participant taking part in the Vivacity programs The undersigned further agrees to defend, hold harmless and indemnify the Company for any liability sustained by said Company as a result of the negligent, willful or intentional acts of the participant. If any suit is brought against the Company all attorneys fees and costs incurred by the Company will be paid by the undersigned if the undersigned does not prevail. The undersigned waives any mirror provisions for attorney�s fees or costs. The undersigned acknowledges that the Company does not provide insurance for participants. In the event that reasonable attempts to reach parents/guardians at phone numbers listed have been unsuccessful, I hereby give my consent for the administration of any and all emergency treatment deemed necessary by licensed physician or the transfer of the participant to the nearest appropriate hospital or emergency facility. I will pay for all medical expenses. I further understand, consent and agree that the Company will not be held responsible for the results of such emergency treatment. In order to promote efficiency, safety and quality of instructions the participant agrees to abide by the rules and regulations governing the conduct and operation of the classes. At the discretion of the Company staff any participant or parent/guardian can be removed from an activity or meeting and in extreme cases have membership terminated without a refund for not meeting behavior standards or not complying with the Company rules or policies. The undersigned grants permission to use participant's name, pictures, visual images, artwork and/or comments, which may be used by the Company in publications and promotions, without compensation to the participant. The undersigned waives all rights to inspect and/or approve such publications and copy or voice-over commentary which may be used in conjunction with the visual images and the uses to which they may be applied. Parents are responsible for picking up their children promptly at the end of a lesson or activity and at the discretion of the Company staff may be charged at the full private lesson rate for being more than 10 minutes late. It is understood that fees cover a set period of time, are not refundable or transferable and that there are no refunds or credits given for missed meetings, activities or lessons. Dues, fees and deposits paid in advance for supplies and services are not refundable or transferable and must be used for the purpose intended. Participant understands that it is his/her responsibility to attend classes. Further, the participant understands that the fees (refer to programs� fees information) are due and payable according to the terms of Membership agreement whether or not the participant chooses to attend classes. I, a participant or parent/guardian of a participant, have read the rules and policies pertaining to this registration and agree to abide by them. If a check is not honored for insufficient funds, stopped payment or any other reason there is a $35 service charge.

I HAVE READ AND FULLY UNDERSTAND ALL OF THE INFORMATION ABOVE.
PARTICIPANT (18+) OR PARENT/GUARDIAN INITIALS