DATE:___________________

Registration Form, 2014-2015 school year

John M Marshall Elementary School

Springs School

Childs Name:______________________________________________________________________
*Mailing Address:__________________________________________________________________
Town:________________________________________ Zip:_________________________________
Home Telephone:_____________________________ Cell:_________________________________
*E-mail:___________________________________________________________________________
Childs Date of Birth:___________________________ Childs Gender:

Female

Male

Childs Birthplace:___________________________________________________________________
Childs Grade Level for 2014-2015: (circle)

Information
Mother/Guardians Name:__________________________________________________________
Place of Employment:_______________________________________________________________
Employers Name:__________________________________________________________________
Employers Phone Number:__________________________________________________________
Father/Guardians Name:___________________________________________________________
Place of Employment:_______________________________________________________________
Employers Name:__________________________________________________________________
Employers Phone Number:__________________________________________________________

Emergency Contact/ Pick Up Authorization (All people other than paretn authorized to
pick up child.)

Name

Relationship

Phone #s

1._________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
OVER

Medical Information (all information will be kept strictly confidential)

1.Does your child have a medical condition that the Staff of Project MOST need to be
aware of?

YES

NO

If YES, please explain:__________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
2. Project MOST is not authorized to administer medication. Does your child take any
medication that we need to be aware of?

YES

NO

If YES, please explain:__________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
3. Are there any ALLERGIES we need to be aware of or any diseases that may be an
issue while your child is in our care?

YES

NO

If YES, please explain: __________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Parent Permission for Services:

I grant permission for my child to use all equipment and participate in all activities at
Project MOST (Karate, Yoga, Dance, Art, Field Trips, cooking).
I grant permission for my child to attend swimming lessons at the YMCA (East
Hampton Town Rec. Center).
I grant permission for my child to leave the school premises under adequate supervision by staff for offsite trips, outside play and recreation activities. I understand these
activities may be taken at any time without further consent from me.
I grant permission for the school district to share school records.
I grant permission for my child to be included in photographs, videos &
electronic newsletters used in Project MOST.
**Please be aware that Project MOST has a Code Of Conduct.
It is always available at our front desk for review.**
Parent/Guardians Signature: ________________________________________________________
Date: _____________________________________________________________________________