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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