Introduction to Elements of Mathematics – 2019 – 2020 Fall Registration Form – First Year

Parent

Name Prefix

First Name *

Last Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone Number

Cell Phone Number

Work Phone Number

Email Address *

Please note: our contact management system does not communicate with Charter email addresses, so we recommend that provide us with an email address from a different carrier.

Additional Parent?

Yes
No

Additional Parent

First Name *

Last Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email Address *

Please note: our contact management system does not communicate with Charter email addresses, so we recommend that provide us with an email address from a different carrier.

Student

First Name *

Nickname

Last Name *

Birth Date *

Current Grade *

Gender *

Race (Optional)

This information is used for statistical purposes only.

Student's Email *

Please provide an email that teachers will use to contact students as part of our Virtual Learning Environment (VLE). You will have an opportunity to provide a parent email in the parent section of this form, to be used for general communication with Project MEGSSS. Please note: our contact management system does not communicate with Charter email addresses, so we recommend that provide us with an email address from a different carrier.

Does your student have any special need(s) of which we should be aware?

Emergency Contact Information

Allergies or Medical Issues *

Yes
No

Does the student have any allergies or other medical issues of which we should be aware?

Please describe:

Parent Emergency Phone Number *

Additional Emergency Contact Name *

Additional Emergency Phone Number *

Primary Physician Contact Name *

Physician Phone Number *

School

Name of School (Current) *

Is the Student a Gifted Program Participant? *

Yes
No

Additional School

Name of School Student Will Attend Next Year, If Different

Is there anything else you would like to share with us at this time?

Authorization

Permission to Publish in Class Listing *

Yes
No

Do you give permission to us to include your student in the class listing (published on our private website only), for carpool purposes?

Permission for Media Releas *

Yes
No

Project MEGSSS may be photographing or videotaping some class sessions for future educational purposes or for use in future efforts to reach new MEGSSS students. Student names will never be used without specific permission. Does Project MEGSSS have permission to photograph/videotape my student in the classroom setting?

Permission to Transport

Yes
No

In case of emergency, I authorize Project MEGSSS personnel to arrange emergency transportation to the nearest emergency room. Project MEGSSS will not be held liable for costs associated with such a decision. I understand that Project MEGSSS personnel will not be responsible for administering any medication required for my child. I further agree that I will update this emergency information form if the information changes. Please note: in the event of a medical emergency, if time permits, a parent will be called first.