Name: _____________________________________

Address: __________________________________

City, State, Zip: _________________________

Day Phone: (____) ____________ Evening Phone (____) ___________

Email Address: _______________________________

Date of Birth

Parent or guardian signature (if under 18): ______________________

Reasons for joining (Check all that apply)

__ Blitz/speed play

__ Camps/workshops

__ Lessons/education

__ Social setting

__ Casual play

__ Club events

__ Tournament play

__ Lectures

__ Other: ______________

When would you use the club the most?

__ Weekday afternoons

__ Weekday evenings

__ Weekend afternoons

__ Weekend evenings

How long have you been playing chess? _______

Memberships are $30 for youth, $80 for adults, and $120 for families. Please return with payment to PO Box 4641, Saint Louis, MO 63108.