Please select one or more race which best describe the child being registered: American Indian or Alaska Native Asian Black or African American

Transcription

1 Somers Central School District P. O. Box 620 Lincolndale, New York Student ID# Family ID# (office use only) Date: STUDENT REGISTRATION DATA PACKET Welcome to the Somers Central School District. All of the information requested on this form is required and must be completed before your child can be admitted. If you should have any questions, please feel free to ask. Student s First Name Middle Last Name Birthdate Gender: Male Female Grade last attended: Grade will enter: Counselor Ethnicity: Hispanic/Latino Yes/ No (please circle) Please select one or more race which best describe the child being registered: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander _ White _ Is English the primary language spoken in the house? Yes No If no, what language? Student is living with: Natural parent(s) (if separated or divorced, custody order required) Legal guardian (guardianship papers required) Foster family (foster child data sheet must be completed) Does your child have an IEP (Individualized Education Plan)? Yes No Is your child involved in CPSE? Yes No 1

2 Father s First Name Father s Last Name Mother s First Name Mother s Last Name Home Phone Father s employment phone Father s cell phone Indicate if telephone is unlisted Mother s employment phone Mother s cell phone Include in Class List address (REQUIRED The district utilizes to send out important information to parents) Student Physical Address House Number and Street City State / Zip Code Student Mailing Address P.O. Box House Number and Street City State / Zip Code Second Mailing Information (if required) Name House Number and Street City State / Zip Code Emergency Contact Information Name Relationship to student Contact Home Phone Physician Name Contact Cell Phone Physician Phone 2

3 OTHER CHILDREN IN HOUSEHOLD Name Date of Birth Gender M F Parent Certification I affirm that the information given in this student application is complete and accurate. I hereby authorize the Somers Central School District to verify any and all information. Any misrepresentation in residency documentation may result in the removal of my child from the Somers Central School District and/or being held responsible for the payment of tuition to the district. Parent / Guardian Signature Date 3

4 Did this child attend a Pre-School program outside your home? Yes No If yes, was it a half or full day program? Half Full Please place a check by the pre-school program which best describes the one this child attended: District Operated Day care center Head Start Family or Group Day Care Nursery School BOCES Special Education Pre-School Non-public school Museum Library Other 4

5 Permission for Release of Student Records Name of School Previously Attended Contact person Address City State / Zip Code Phone Number Fax Number I hereby request that a copy of all of student s name school records, including psychological, school social work reports and/or Committee on Special Education records and relevant medical records be released and forwarded to the Somers Central School District at the address indicated below. Parent / Guardian Signature Date Check one: Ms. Katie Winter, Principal, Primrose Elementary School, P.O. Box 630, Lincolndale, NY Ms. Stacey Elconin, Principal, Somers Intermediate School, 240 Route 202, Somers, NY Ms. Maryellen Coogan, Guidance Dept., Somers Middle School, 250 Route 202, Somers, NY (Fax #: or mcoogan@somersschools.org) Ms. Deborah Hardy, Dir. of Guidance, Somers High School, P.O. Box 640, Lincolndale, NY Ms. Anna Maggio, Director of Special Services, Somers School District Office, P.O. Box 620, Lincolndale, NY (Fax #: or lcostas@somersschools.org) 5

6 1. Information regarding child s biological or adoptive father: Name: Home Address: Home Telephone: Employer: Employer Location: Employer Telephone: Information regarding child s biological or adoptive mother: Name: Home Address: Home Telephone: Employer: Employer Location: Employer Telephone: 2. Does the child s parents own real property in this school district? If yes, please give address: Does the child s parents rent real property in this school district? If yes, please give address: 3. To what extent will be care, custody and control of the child be exercised by: BE SPECIFIC. the person that the child lives with either parent 4. Does either parent or person with whom the child lives maintain another residence elsewhere? If yes please give address: Time spent there: 5. Does each parent intend to remain at his/her present address? 6. Where is each parent registered to vote? Mother Father 6

7 7. Does either parent hold a driver s license? If so, from where? 8. For what address/property is each parent/guardian billed as a resident taxpayer? 9. To what extent is the child s support provided by (a) the person that the child lives with? (b) either parent? BE SPECIFIC. 10. Is the child covered by health insurance? If yes, in what adult s name is the policy issued or coverage provided? 11. What court orders have been made with respect to the child s guardianship or custody? Attach copies of orders. Date Court Arrangements 12. If the child is residing in a district other than that of either parent, describe the reason and purpose for such an arrangement including whether both parents have consented to such arrangements. BE SPECIFIC. 13. Does either parent retain the right to recall the child from the person with whom the child lives? If so, under what circumstances? 14. Who is to receive school mailings and be contacted in case of an emergency involving the child? 15. Does this child temporarily live in the Somers School District for the primary purpose of allowing the child to attend Somers Schools? 16. Who claims the child as a dependent on their Federal Income Tax Return? You may be required to supply the first page of the return. Signature of Parent or Signature of Guardian 7

8 FOR SCHOOL OFFICE USE ONLY Start Date First time registrant Re-registrant SCHOOL SHS SIS Primrose SMS Residency Information (all information must be current within the last 3 months) Homeowner: Tax Bill Mortgage Statement Contract of Sale Renter: Lease Notarized Affidavit of Landlord and Landlord s School or Town Tax Bill Exception Code (if applicable) ESL SE Foster Tuition Out-of-District Placement: Authorized by: School placement: SCHOOL OFFICE PERSONNEL MUST SIGN BELOW TO VERIFY THAT THEY HAVE CONFIRMED ALL THE INFORMATION GIVEN BY PARENT/GUARDIAN REGARDING STUDENT AND RESIDENCY. School Office Personnel Date 8

9 Somers Central School District Education Program for Homeless Students Must be completed by all Registrants The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney- Vento Act are entitled to immediate enrollment in school even if they do not have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services. Where is the student currently living? (Please check any that apply or select None of the above) in a shelter in a motel or hotel in a transitional housing program in a car, trailer or campsite in a rented trailer/motor home on private property in a SRO building (single room occupancy) in a rented garage temporarily with an adult that is not the parent/legal guardian due to loss of housing temporarily in another family s house/apartment due to loss of housing awaiting foster placement other places unfit for human habitation None of the above apply Print Name of parent, guardian, or Student (for unaccompanied homeless youth) Signature of parent, guardian, or Student (for unaccompanied homeless youth) Date 9

10 The University of the State of New York The State Education Department Office of Bilingual Education Albany, New York Home Language Questionnaire (HLQ) Dear Parent or Guardian: DISTRICT SCHOOL TO BE COMPLETED BY SCHOOL PERSONNEL Please print or type clearly GRADE In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes English. Your assistance in answering these questions is greatly appreciated. Thank You STUDENT NAME DATE OF BIRTH Month: Day: Year: STUDENT IDENTIFICATION NUMBER COUNTRY OF BIRTH / ANCESTRY NUMBER OF YEARS ENROLLED IN SCHOOL OUTSIDE THE U.S. NAME/POSITION OF SCHOOL PERSONNEL COMPLETING THIS SECTION DETERMINATION: Possible LEP English Proficient ( boxes that apply) 1. What language(s) is spoken in the student s English Other home or residence? specify 2. What language(s) are spoken most of the time English Other to the student, in the home or residence? specify 3. What language(s) does the student understand? English Other specify 4. What language(s) does the student speak? English Other specify 5. What language(s) does the student read? English Other Does Not Read specify 6. What language(s) does the student write? English Other Does Not Write specify 7. In your opinion, how well does the student understand, speak, read and write English? Very well Only a little Not at all Understands English Speaks English Reads English Writes English Month: Day: Year: Signature of Parent/Guardian/Other 10 Date HLQ (2/00) PM

11 Matthew Carr Human Resources & Student Services Manger Dear Somers Parent/Guardian: As a district, we are always looking for ways to celebrate the good work of our students and staff. Our school website, as well as our school T.V. station, Channel 18, provides two forums in which to highlight some of the great work being produced by our students. From time to time, we would like to post exemplary student work on our website. We also plan on airing a series of programs which spotlight various curricular initiatives on Channel 18. These programs may involve the filming of specific classrooms where children are engaged in various learning activities, in addition to the traditional programming seen on Channel 18 like athletics, music, and the arts. PLEASE SIGN ONLY IF YOU OBJECT TO HAVING YOUR CHILD INVOLVED IN EITHER OF THE BELOW OTHERWISE DISREGARD If you object to having your child involved in either of the above, please indicate below, sign and return this form to the main office of your child s school. I do not want my child s work displayed on the school website. _ I do not want my child involved in any special programs on Channel 18. Parent/Guardian Signature _ Child s Name _ Please Print Child s School _ Please Print 11

12 Matthew Carr Human Resources & Student Services Manager Dear Somers Parent/Guardian: The Somers Parent Teacher Association (PTA) would like to welcome your family to our District. If you are interested in being contacted, please give us permission by completing this form. We will provide your contact information to the Somers PTA. Please Print Name: _ Address: address: Telephone: Student Name: Grade: Parent/Guardian Signature _ Date P.O. Box 620, Lincolndale, New York Route 202, Somers, New York Voice (914) Fax (914)

13 SOMERS CENTRAL SCHOOL DISTRICT TRANSPORTATION REQUEST PLEASE PRINT DATE I AM HEREBY REQUESTING BUS TRANSPORTATION FOR WHO WILL BE ATTENDING DURING THE SCHOOL YEAR. Male Female Grade Level Date of Birth Print name of parent or guardian Signature of parent of guardian Street Address Include a landmark if possible Mailing Address Address Home Telephone Number Work Telephone Number Cell Phone Number Starting Date 13