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School Year 2022 - 2023

Please call 801-596-8489 if you have any questions.

WELCOME TO CITY ACADEMY!

Student Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Student Birth Date

Student Grade

Parent Name:

Parent Place of Work:

Parent Occupation:

Parent, please indicate your highest level of education:

		GED
		High School
		College - 2 years
		College - 4 years
		Masters Degree
		Other

NEW STUDENTS ONLY:

Health/Medical/Learning Concerns

Please describe any health or medical (including emotional/mental) concerns or learning concerns the student has, or any 504 plan or IEP information of which City Academy should be aware so that we can best support your student.

Concerns:

Has your student been suspended or expelled from any previous school?

If so, please indicate which school and briefly explain circumstances:

Has your student received any truancy (attendance) citations during the previous school year?

If so, please indicate which school and briefly explain circumstances:

ALL STUDENTS:

Medical Consent Agreement

In the event of medical emergency, when parent or guardian cannot be reached or in life threatening situations, I authorize City Academy to obtain emergency medical care (i.e., physician, dentist, paramedic, or other authorized emergency medical agents) and to obtain and provide emergency transportation. I understand that I or my insurance, if applicable, will be billed for such emergency medical treatment.

I agree to the above Medical Consent Agreement

Mandatory Fees

Check here if you expect to qualify for free meals/fee waiver. Mandatory fees are waived if you qualify. Application form will be available in August.

Fee Waiver

Partial payment of required fees is due now.

The balance will be due in August

Partial Payment of Mandatory Fees for Grades 7,8:

$170.00

Select:

Item Subtotal:

$0.00

Partial Payment of Mandatory Fees for Grades 9-12:

$195.00

Select:

Item Subtotal:

$0.00

Mandatory Fees include the following: Activity Fee, instructional & laboratory materials, texts, technology, software, equipment licenses, and transportation fee.

Optional

Parent School Organization (PSO) Donation:

$5.00

Select:

Item Subtotal:

$0.00

Donation to City Academy:

Item Subtotal:

$0.00

To help cover fees for families who cannot afford to pay them.

Total:

$0.00

Payment Information:

Processing Fee Rates:
Cards:	3% plus $0.50 (1.5% surcharge for foreign cards)
eCheck:	$0.50

Method of Payment:
Update Name from Personal/Organizational Information

Name on Account:
Routing Number:
Account Number:
Institution:

Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:

Change Payment Method

New Students - Please remember the following things need to be done:

Call to schedule and attend a meeting with our school director or counselor (801)596-8489
Submit the following items to the school office:

Birth Certificate
Immunization Record
Transcript or most recent report card
IEP/504/ESL (if applicable)

ALL STUDENTS:

Click on the "Continue" button below to submit this information and click the link on the next page to complete your registration!

We are looking forward to another great year at City Academy!

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