Millpond Academy Registration

Millpond Academy Registration
Additional requirements for registration

Bring this registration form and the following documentation to the school.

• Birth Certificate or Passport
• Current Immunization Record

A nonrefuldable deposit of $200 per child must be paid at time of registration to secure your space. Tuition payment options will be sent out with your contract.
Student Information
Name

First Name Last Name
Gender
Birth Date

Month Day Year
Date
Applying to Grade
Entry Year
First Language
Second Language(s)
Primary Residence Information
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Information
Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email address
Phone Number

Area Code Phone Number
Additional Parent/Guardian Information
Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email address
Phone Number

Area Code Phone Number
Custodial information if applicable.

Emergency and Medical Information
Family Doctor

First Name Last Name
Health card number
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns, conditions,
Emergency Contact 1
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship:
Emergency Contact 2
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
In case of an emergency I, blanks give permission for my child,blank, to receive medical treatment.

Additional Person(s) with Permission to Pick Up/Drop Off
Person 1
Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Person 2
Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number

Previous School 1
School Name
City, Province
Date Started

Month Day Year
Date
Date Ended

Month Day Year
Date
Previous School 2
School Name
City, Province
Date Started

Month Day Year
Date
Date Ended

Month Day Year
Date
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform