Queen's University
Program Registration

Create New Account

To create a new account on the system, please fill in the form below. Once you have completed the following form, click on the 'Create Account' button. Your account will be created and your new username and password will be sent to you via email.

New Student Information
Title:
* First Name:
* Last Name:
Family:
Date of Birth:
* Gender:
Student Address Information
*Address 1:
Address 2:
*City:
*Province:
*Postal Code:
*Country:
*Phone Number:
Fax Number:
* Email:
Email Opt Out:
Please not that this includes all reminders and receipt emails
Medical Information
Health Card #:
* Type:
* Description:
* Medication Name:
Requires Refrigeration: This medication requires refrigeration
* Medication Purpose:
* Instructions:
Additional Information:
Confidential:
Account Information
* Username: