Chess In The Schools Chess Program Application Form

Fields denoted by an asterisk (*) are required.

* Is your school a Title 1, New York City School?:
Yes
No

If yes, continue to fill out the rest of the form. If no, stop. Your school is not eligible to participate in the Chess-in-the-Schools Chess Program. Please read about our Project Chess Program.

General Information

* School #:
* School Name:
* Region #:
* Address Line 1:
Address Line 2:
* City:
* State:
* Zip Code:
* Telephone:
* Fax:
* Email:
* Principal Name:
* Principal Telephone:
* Principal Email:

School Information

Please use data for the current year.

* Total Enrollment of Students:
* Percent (%) of Students Eligible for Free Lunch:
* Percent (%) of Special Education Students:
* Percent (%) ELL:
* Ethnic Composition (check all that apply):
American Indian or Alaska Native
Black or African American
Hispanic or Latin
Asian or Native Hawaiian/Other Pacific Islander
White, non-hispanic
* Percent (%) of Bilingual Students:

Number of classes per grade

Elementary:

Kindergarten:
1st grade:
2nd grade:
3rd grade:
4th grade:
5th grade:

Junior High Schools:

6th grade:
7th grade:
8th grade:

High School:

9th grade:
10th grade:
11th grade:
12th grade:

Which Junior High Schools will your students attend?

School #1:

Region:
School:
Percent (%) of Student Attending:

School #2:

Region:
School:
Percent (%) of Student Attending:

School #3:

Region:
School:
Percent (%) of Student Attending:

School #4:

Region:
School:
Percent (%) of Student Attending:
Is your school a:
Magnet School
Charter School
Empowerment School
Are there any organizations providing programming in your school this year?:
Yes
No

If yes, please provide the following:

Organization #1:

Name of organization:
Program Description:
Grades Served:
# of Students served:
Programs during school day:
After-school programs:

Organization #2:

Name of organization:
Program Description:
Grades Served:
# of Students served:
Programs during school day:
After-school programs:

Organization #3:

Name of organization:
Program Description:
Grades Served:
# of Students served:
Programs during school day:
After-school programs:

Please enter the contact information of the staff member from your school that will be responsible for ongoing communication with Chess-in-the-Schools as the Chess Coordinator below.

Name:
Job Title:
Telephone:
* Email:

Please enter your contact information in case we need to contact you regarding this submission.

Name:
Telephone:
Email:
 

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