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 NameLast Name
Gender
Birth Date *

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information
Name*

First NameLast Name
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address *
Phone Number*

Area CodePhone Number
Additional Parent/Guardian Information
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
Phone Number

Area CodePhone Number
Custodial information if applicable.

Emergency and Medical Information
Family Doctor

First NameLast 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 NameLast Name
Phone Number*

Area CodePhone Number
Relationship:*
Emergency Contact 2
Name*

First NameLast Name
Phone Number*

Area CodePhone 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 NameLast Name
Relationship
Phone Number

Area CodePhone Number
Person 2
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number

Previous School 1
School Name
City, Province
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Previous School 2
School Name
City, Province
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
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.
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