Movie Program Registration

Please complete the form shown below and submit with your payment for the Bing Movie Program.

Director: David Horgan, (413) 348-0705.

All fields below marked with an asterisk* are required for registration.

    Student Information

    First Name*:Last Name*:Date of Birth*:

    Home Phone*: Cell Phone*: Gender*:

    Address:*City*:State*:Zip*:

    School*:Grade Entering in Fall*:

    Parent Information

    Name(s)*:Mobile Phone*:

    Employer:Business Phone:

    Emergency Contacts

    Please list names, addresses and telephone numbers of any person to whom your child may be released and persons to contact when you cannot be reached:

    Name:*Address*:Phone*:Relationship*:

    Name:Address:Phone:Relationship:

    Name:Address:Phone:Relationship:

    Name:Address:Phone:Relationship:

    Personal History

    The language primarily spoken at home is:*

    Does your child have any of the following (if yes, please explain):

    Allergies including food allergies:Does your child carry an EpiPen?

    Previous serious illness or injuries:Any medication for long term use:

    *Note: No medications will be administered during the program.

    Are there any other problems regarding your child’s health and/or behavior which you feel we should be aware of?

    Authorization for Emergency Medical Attention

    In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

    Name of Physician*:Address*:Phone*:

    If the Physician is unavailable or any injury/illness requires a hospital setting, your child will be taken to Baystate Medical Center in Springfield, MA, as the closest emergency medical facility.

    Consent & Agreement

    Please select a response for each authorization item below:

    I give consent for the the Bing to transport my child via approved vehicles for any off-site outings.*:

    I give consent for the Bing to provide lunch and snacks for my child.*:

    I will make the Bing staff aware of any allergies or dietary restrictions for my child.*:

    I give consent for the Bing to secure any and all necessary medical care for my child.*:

    I give consent for the Bing to provide emergency first aid and CPR on my child if required.*:

    I agree to review the movie program rules with my child.*:

    I agree to review the movie program rules with my child.*:

    I give consent for the Bing to take photographs and video tape with my child in it, due to the nature of the media program and for the purpose of program marketing.*:

    By signing this document, I agree to and understand all of the items listed above and will contact the program director, should I have any questions or concerns.

    Parent Name:*Student Name:*

    Date:*E-mail Address:*