2017SPECIAL EDUCATION REGISTRATION ESY
Please provide the following information to register your child for summer school. Be sure to download the emergency contact form and/or medication form and send to Kristin Robertson at Mill Pond School.
Student's LAST name
Your answer
Student's FIRST name
Your answer
Student's gender
Was the student recommended for Extended School Year (ESY) services at his/her IEP meeting?
What is your student's CURRENT grade in school
What school does the student CURRENTLY attend
Name(s) of Parents(s)/Guardian(s)
Your answer
Home phone number
Your answer
Cell phone number
Your answer
Email
Your answer
Address
Your answer
Will the student need transportation TO Mill Pond (does not include walk-in services)
Will the student need transportation home FROM Mill Pond
Will you be enrolling your child in the Westborough Community Education Summer Camp? (enrollment is required through Community Education and is separate from special education summer school programming)
If your child will attend community education summer camp does he/she need transportation to WHS at 12:00?
Please list any days during summer school (July 10 - August 10, 2017) that you know the student will be absent
Your answer
In case of emergency who should the nurse contact if parents/guardians are unavailable? Please include Name and Phone Number
Your answer
Does the student have any allergies? If yes, please list
Your answer
Please provide the name of phone number of the student's doctor.
Your answer
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