Player Name: ___________________________________________________________________________

Birth Date: ____________________________________

[  ] Male    [  ] Female

USCF Number (if you have one): ____________________________

Exp. Date: __________________

Check if you are   [  ] joining USCF      [  ] renewing USCF membership

Youth

$21

19 years and under - Receives 6 issues of Chess Life Magazine

Scholastic

$15

14 years and under  - Receives 5 issues of Chess Life Magazine and 1 Scholastic Yearbook magazine

                USCF dues: $__________

Indicate the events you want to play in

[  ]

Challenge

June 29, July 6, 13, 20, 27, August 3

[  ]

First Reserve

June 29

July 6

July 13

[  ]

Second Reserve

July 20

July 27

August 3

Enter the applicable entry fee:

$12 for one Reserve Event

$20 for both Reserve Events

$20 for the Challenge Event

Entry Fee: $__________

Total dues and entry fees:

$___________

Parent/Adult Name(s):    ___________________________________________________________________

Address:_______________________________________________________________________________

Telephone (including area code): _________-_________-_____________

Email: ______________________________________________________________________

Write check for the total amount, payable to MetroWest Chess Club