Fun with Chess Application for Instructor

Name

Email Address

Cell Phone (xxx-xxx-xxxx)

Home Phone (xxx-xxx-xxxx)

Emergency Number (xxx-xxx-xxxx) If we cannot reach you at the home or cell number

Street Address

City

State

Zip Code

Date of Birth (mm/dd/yyyy)

Experience

References

Days Available (between 2:00 and 6:00 PM Days Available (between 2:00 and 6:00 PM Monday Tuesday Wednesday Thursday Friday

Instruction Location Preference - check all that apply Instruction Location Preference - check all that apply Chicago South Suburbs Chicago South Side Chicago West Side Chicago North Side

Other Times Other Times Saturdays I can work during Summer Vacation I can work during Spring Break I can work during Summer Break None of the above