Southern Connecticut MENSA

www.us.mensa.org

SCM is taking a poll of members interested in the game of Chess, in an effort to gauge the potential for forming a group that would meet on a regular basis to play against one another.

If you are a member of SCM, please fill out and submit the questionnaire below. All information submitted will be kept confidential. If there is enough interest, respondents will be contacted and a regular Chess event will be organized and scheduled.

Your Name:

Email Address:

Email Address Again:
(for verification)

Phone #:

I Am Willing To Meet:
(Check all that apply)

Any Day Between and

------- OR: -------

Monday Between and

Tuesday Between and

Wednesday Between and

Thursday Between and

Friday Between and

Saturday Between and

Sunday Between and

Best Location For Me:
Within A Mile Radius of This Town:

I Am Willing To Act As Coordinator For This Event:
Yes: No:

I Am Willing To Host This Event In My Home/Apartment:
Yes: No: