Virtual

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

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)

1:1 Tuition – Virtual – Novices and Learners [UK] 1:1 Tuition – Virtual – Novices and Learners – Monday to Thursdays – Between 15:00 and 17:00 EST [USA] 1:1 Tuition – Virtual – Novices and Learners – Fridays – Between 12:00 and 14:00 GST [UAE] 1:1 Tuition – Virtual – Novices and Learners – Saturdays – Between 09:00 and 11:00 GST [UAE] 1:1 Tuition – Virtual – Novices and Learners – Sundays – Between 09:00 and 11:00 GST [UAE]

Other Details We Should Know

Full Name of Parent / Guardian Completing and Signing the Declaration

Booking Received