DEMAREST PUBLIC SCHOOLSREGISTRATION FORM

Grade

Date

Student Name

Home Address

Family E-Mail

Age

Home Phone

Date of Birth Gender M

Place of Birth** Birth Certificate Presented(City) (State)

Father's Name

(Country)

Phone

(Required within 30 days of enrollment)

Mr. Dr. (Please circle one)

Address (If different from above)

Mother's Name

Home Business Cell

PhoneMrs. Dr. (Please circle one)

Address (if different from above)

Home Business Cell

Guardian's Name

Address

PhoneHome Business Cell

Person Enrolling Student Relationship to Student

Address Phone

Primary Language

**Ethnicity

(If different from above)

Language Spoken at Home

(See back of form for explanation of ethnicity)

Emergency Contact Name/Relationship Phone

Home Cell

Last School Attended

Grade Completed

Name Address

or Current Grade Level Proof of residence submitted

Date Left

NAME

***List all children in family- in age order including student***

BIRTH DATE CURRENT GRADE LEVEL

Demarest Public Schools Emergency Information CardPlease Print AH Information Grade/Class

Student's Name Birth DateLast First Month/Day/Year

Address Home Phone #

Mother's Email Address Father's Email Address:

Parent/Guardian: To serve your child in case of accident/ sudden illness, it is necessary that you give the following information for emergency calls:Mother's Name Work# Cell #Father's Name Work # Cell #

Address of Non-custodial Parent if pertinent. AddressList 2 neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached.Name RelationshipHome # Work # Cell #_Name RelationshipHome # Work # Cell #In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physicians named belowand follow their instructions. In the event that it is impossible to contact the physician, school officials are hereby authorized to take whatever action is deemed necessary forthe health of the aforesaid child. I will not hold the school district responsible for the emergency care and/or transportation for said child.Local Physician's Name Office #Local Dentist's Name _ Office #

Parent Signature Date

Does your child have health insurance? Yes If Yes, Name of insurance company?No NJ Family Care provides free or low cost health insurance for uninsured children and certain low-income parents. For more information call 800-701-0710 or visitwww.njfamilycare.org to apply online.You may release my name and address to the NJ Family Care Program to contact me about health insurance.

Signature Print Name: _ Date:Written consent required pursuant to 20 U.S.C. 1232g (b)(l) and 34 C.F.R. 99.30 (b)

DEMAREST ELEMENTARY SCHOOLSDEMAREST, NEW JERSEY

INFORMATION FORM FOR NEW STUDENTS

The following information is provided to assist teachers in integrating thestudent into our school.

If you require additional information, please ask Mrs. Daly, school secretary,Mrs. Williams, school nurse, or Mr. Mazzini, school principal.

Student Name:

Date of Birth:

Language spoken at home:

Previous preschool attended:

Does your child wear glasses: YES: NO:

Does your child wear hearing aids: YES: NO:_

Physician name and phone number:

ALLERGIES: YES NO

If yes , please describe:

Parent Portal Questions - 2017/2018Circle Y/N

1.

2.

3.

4.

5.

6.

L

8,

9.

10.

11.

12

Permission is granted for a photo/image that includes this student without anypersonal identifiers to be published in the media or district publication, includingthe district's website.

Nurse has permission to share student's medical information with appropriatestaff.

Permission is given to provide the PTO with my child's name, address, andtelephone number for class lists for social purposes and/or informationalmailings.

Demarest School District can provide address information to the Northern ValleyRegional High School District for information and mailing purposes.

1 have read and discussed the HIB information located on the school's homepagewith my child.

1 agree to permit my child to ride their bicycle to school in accordance with theBicycle Agreement as posted on the school website.

1 agree to the Activity Agreement as posted on the school website.(This question must be answered yes in order for the student to travel within district)

My child has permission to leave school at normal daily dismissal time"UNESCORTED" which means my child will be released without any parentalsignature reauired. 1 acknowledge that the district shall incur no liabilitv as aresult of allowing my child to leave school unescorted.

(This question must be answered YES unless the parent comes in to the main office to signtheir child out each and every day at dismissal time)

1 have read and understand the contents of the Student Handbook.

My child has permission to be dismissed unescorted in the event of anemergency school closing. If you choose ''NO" then you must add an emergencydismissal contact under the "CONTACTS" tab. When doing so please be sure tochoose "EMERGENCY DISMISSAL CONTACT" under the drop down menu.My child and 1 have read the Technology Use Policy and understand and abide bythose terms and conditions for access to the Demarest School District'selectronic network account. We further understand that any violations of theregulations are unethical and may constitute a criminal offense. We understandthat any violation of the noted guidelines and regulations could result in therevocation of the students' access rights, the imposition of school discipline,criminal prosecution and other legal action.

Does your child have health insurance?If yes, name of insurance company? (Optional)

If no, NJ Family Care provides free or low cost health insurance for uninsuredchildren and certain low-income parents. For more information call800-701-0710 or visit www.nifamilycare.org to apply online.You may release my name and address to the NJ Family Care Program to contactme about health insurance.

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

Yesrelease my

name &address

DEMAREST PUBLIC SCHOOLS, DEMAREST, NEW JERSEYPHYSICAL AND IMMUNIZATION RECORD Grade

Name (Last) (First) Address

Birthdate

PHYSICAL REPORT: Ht:

Parent's Name

Wt: BP:

Phone #

Hearing: R L_

Vision: R20/ L20/ Laboratory: Urinalysis HGB/HCT Otherwith/without glasses (Circle)

Respiratory_

Cardiovascular_

Abdomen Genitalia Skin

Musculosketal Neurological_

RECOMMENDATIONS1 . Any defect of vision, hearing or speech that the school

could compensate for by proper seating, etc.?2. Any condition limiting classroom activity?

Any condition limiting physical education?3. Any significant allergies or asthma?

4. Any condition which may result in classroomemergency?

5. Any emotional, mental or physical condition requiringperiodic medical observation?

6. Any medication taken on a daily basis?

NO YES Comments

VACCINE TYPE

DIPHTHERIA, TETANUS, PERTUSSIS- DTP(If DT or TD, indicate in corner box)

POLIO - Oral Polio Vaccine(OPV)(If Salk Vaccine, indicate IPV in corner box.)

MEASLES, MUMPS, RUBELLA (MMR)

MEASLES

RUBELLA

MUMPS

VARICELLA

HAEMOPHILUS B (HIB)

HEPATITIS B

DISEASEDATE

1STDOSEMo/Day/Yr

2nd DoseMo/Day/Yr

3rd DoseMo./Day/Yr

4th DoseMo/Day/Yr

5lh DoseMo/Day/Yr

Mo/Day/Yr

Mantoux Date Tested Date Read Result (mm CXR (date) Normal Abnormal Meds. Prescribed (Date)

Date of examination: Physician's Signature

Physician's Address^

Phone Number 1/17

Demarest Public School DistrictDemarest, New Jersey 07627

Dear Parent/Guardian:

Welcome to the Demarest Public School System. Registering your son/daughter requires that the following information beincluded and submitted to the Health Services Department. (These requirements are mandated for all students enteringKindergarten thru Fourth grade. Additional immunization requirements are mandated for students entering Fifth thruEighth grades.)

1. Record of physical examination within 1 year of the date of school entry.2. Immunization record consisting of Primary Series and booster doses as listed below. (N.J.S.S.C. Chapter 14

requires immunizations must be complete and up-to-date or student may be excluded from school.)

D.P.T. - must have a minimum of 4 doses-one dose must be on or after the 4th birthday. (A childwho has received a total of 5 doses will be in compliance with this regulation.)(NOTE: If child is over age 7, a combination of D.P.T., DTaP and/or T.D. totaling3 doses is acceptable.)

Polio - must have a minimum of 3 doses — one dose must be on or after the 4th birthday. (A childwith 4 doses of polio vaccine spaced by a minimum of one month will also be in compliance with thisrequirement.) (NOTE: For children age 7 or older, 3 doses of OPV or IPV will be in compliancewith this regulation.)

Measles- Mumps - Rubella - must have 2 doses of a Measles containing vaccine given on or after the1st birthday. They must have 1 dose of Rubella and 1 dose of Mumps vaccine on or after the child's1st birthday. (Any child who has 2 doses of the MMR vaccine on or after the first birthday, given onemonth apart, will be in compliance with this regulation.) (NOTE: Documented laboratory evidence ofimmunity will also be acceptable.)

Hepatitis B Vaccine - must have completed 3-dose- hepatitis B regimen. This regulation concernsall children entering Kindergarten or 1st grade after 9/1/01 and born after 1/1/96, and for childrenentering grade 6 after 9/1/01 and born after 1/1/90. (Also, the special 2-dose hepatitis B adultformulation is acceptable if both doses are given between 11-15 years of age.)

Varicella -All children born on or after January 1st, 1998, will be required to have one dose of thevaricella (chicken pox) vaccine prior to entry into the school system. The vaccine must be administeredno earlier than the 1st birthday. (A physician or parent's statement of previous varicella infection ordocumented laboratory evidence of immunity will be acceptable.)

3. Mantoux Tuberculin Test- Required on students entering the school system from out of country unlessexempted by the NJDHSS 2015-2016 regulations. Valid only if administered within the previous sixmonths. It is recommended that all entering children have documentation of one Mantoux test.

YES is required. NO is not required.

Students transferring within the state must bring their records with them to enter. Students entering from out of state have atwo (2) week grace period in which to obtain records. Students entering from out of the country have a thirty (30) day graceperiod in which to obtain records. If records are not received within the stated time, the students will be excluded fromschool. Your cooperation is essential! If you have any questions, please contact the school health office.

Very truly yours,Meaghan M. Williams, RNSchool NurseCounty Road School

I have read and understand the rules of registration concerning immunization requirements.

Student's Name Grade_

Parent/GuardianS ignature Date_

1/17