2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number*
8. Participant is the same as above

   1. Yes
10. Participant First Name
11. Participant Last Name
13. Mailing Address, City, Zip*
14. Reply Email*
16. Youth Phone*
17. Youth Email
19. School
21. Date of Birth*
    Date of Birth
22. Ethnicity:

    1. Hispanic or Latino
    2. White or Caucasian
    3. Black or African American
    4. American Indian or Alaskan Native
    5. Asian
    6. Prefer not to say
23. Grade:***

    1. K
    2. 1ST
    3. 2ND
    4. 3RD
    5. 4TH
    6. 5TH
    7. 6TH
    8. 7TH
    9. 8TH
24. How did you hear about this program? Please place a to which category (or categories) apply to you:*

    1. Postcard/Direct Mailing
    2. Social Media
    3. School
    4. Town’s Website
    5. Email
26. Emergency Contact Name***
28. The following have permission to pick up my child:***
29. Food Allergies or Other Health Concerns:*
31. I give permission for my child (ren)**

    1. I agree - Chess Club

    I give permission for my child to attend the Town of Southampton Youth Bureau’s Chess Club program at the Flanders Youth Center, 655 Flanders Road from January 6th 2026 - June 16th 2026. I hereby shall release liability, waive any claims against, indemnify, defend and hold harmless the Town of Southampton, its officers, employees, contractors, agents and representatives from and against any and all demands, liabilities, losses, damages, expenses (including reasonable attorney’s fees) and judgments relating to or arising from my child’s participation in the Town of Southampton Youth Bureau’s Chess Club program. I certify that my child’s health and physical condition are appropriate for participation in these physical activities. In the event of a medical emergency and I cannot be reached, I authorize the Town of Southampton Youth Bureau staff to seek emergency medical treatment. I also consent to photographs and video being taken of my child, understanding they may be used for promotional purposes.

33. Service (Convenience) Fee:

    A convenience fee of 2.5%, with a minimum fee of $1.95, will be charged by CSG Forte for transactions made with a Visa, MasterCard, Discover, or American Express card. Your personal information will not be shared with marketers or unaffiliated third parties.

35. Registration Fee*
    -- Select One --Fee/12 sessions - $60.00
36. Cost of Activity
Leave This Blank:


42. Calculate Totals Proceed to Checkout

* indicates a required field