Queens Park

Student Full Name

Date of Birth (YYYY-MM-DD)

Gender(required)

Male Female

Student Permanent Street Address and Postcode

Chess Level (required)

Learner (Cannot play independently) Novice Intermediate Advanced

School Name

Member of School Chess Team(required)

Yes No

If you have been referred to Kensal Life, please enter their name here:

Parent / Guardian (1) Name

Parent / Guardian (1) Address – if different to the Child’s

Parent / Guardian (1) Phone Number

Parent / Guardian (1) Email

Parent / Guardian (2) Name

Parent / Guardian (2) Address – if different to the Child’s

Parent / Guardian (2) Phone Number

Parent / Guardian (2) Email

I want to book :(required)

Group – Spring Term – Monday 16:00 to 16:45 = March (2, 9, 16, 23) = £100 Group – Spring Term – Monday 17:00 to 17:45 = March (2, 9, 16, 23) = £100 Group – Spring Term – Tuesdays 16:00 to 16:45 = March (3, 10, 17, 24) = £100 Group – Spring Term – Tuesdays 17:00 to 16:45 = March (3, 10, 17, 24) = £100 Group – Spring Term – Wednesdays 16:00 to 16:45 = March (4, 11, 18, 25) = £100 Group – Spring Term – Wednesdays 17:00 to 17:45 (10+ Years) = March (4, 11, 18, 25) = £100 1:1 Tuition – In Person – Jasmine Paton – Novice to Advanced [London, UK] 1:1 Tuition – In Person – Paresh Dholakia – Novice & Learners [London, UK]

Discounts

Siblings – Sibling is an existing or previous KL Chess Customer

Other Details We Should Know (e.g. Special Educational Needs)

Full Name of Parent / Guardian Completing and Signing the Declaration

Your booking has been received. We will send you booking confirmation in due course.