Chess Club and Scholastic Center of Saint Louis Membership Form

Name: _____________________________________

Address: __________________________________

City, State, Zip: _________________________

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

Email Address: _______________________________

How did you hear about us?: _______________________________

Date of Birth

___ / ___ / ___

Parent or guardian signature (if under 18): ______________________

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