Rockaway Township Board of Education 16 School Road

P.O. Box 500 Hibernia, NJ 07842

PHONE # 973-627-8200 EXT 200 FAX # 973-627-7968

KINDERGARTEN

***PLEASE DO NOT PRINT THESE COPIES DOUBLE SIDED***

Please return the registration forms to the Board of Education Office along with: 1. Completed Registration Packet with Health Forms which can be printed from our website(www.rocktwp.org) 2. Child’s original birth (BIRTH CERTIFICATE MUST BE PRESENTED AT TIME OF REGISTRATION.)3. Transportation Form (must be filled out even if your child will not need transportation)4. Completed Physical and Immunization Records and signed by your doctor after September 6, 2016 andcompleted before the start of school September 7, 2017. 5. Proof of Residency: MUST provide (along with a photocopy) ONE document from Category A and TWOdocuments from Category B.

Category A - MUST PROVIDE ONE (1) DOCUMENT The most recent real estate tax bill showing you as the taxpayer A signed lease for your residence. Lease must be current. We cannot accept an expired lease. If lease expires

before the first day of school, you will need to present a new lease. A signed deed for your residence A closing statement for the purchase of residence A notarized affidavit from the owner of the residence and yourself stating that you reside at that residence on a

full time basis along with the owner’s tax bill or lease and 2 utility bills with the owners name and address.

Category B - MUST PROVIDE TWO (2) different Utility Bills with the same name and address as above. Gas, electric, oil, water, or phone bill dated within the past 3 months

No child will be permitted to enter kindergarten unless ALL of the above has been completed.

INCOMPLETE PACKETS WILL NOT BE ACCEPTED!

***PLEASE DO NOT PRINT THESE COPIES DOUBLE SIDED***

Thank you,

ROCKAWAY TOWNSHIP PUBLIC SCHOOLS STUDENT REGISTRATION FORM

Last Updated on January 29, 2016 PLEASE PRINT ALL INFORMATION

DIRECTIONS TO PARENT/GUARDIAN: The following questions on this form must be administered at the time of student enrollment. Some responses are optional to protect the privacy of student or family, however, the parent or guardian should understand that his/her responses to these questions will be of great help to the district and the state in planning a program that meets the unique needs of his/her child. If the parent or guardian declines to respond to a question, leave the item blank. The Commissioner of Education has authorized school districts to request this information which will be used in the generation of a State Identification Number (SID) to uniquely identify students enrolled in public schools. The SID is used to monitor student performance data so that higher quality research can be obtained for the purpose of determining improved policies and programs in New Jersey’s public education system.

PUPIL INFORMATION ____________________________________________________________________________________________________________ Last Name First Name Entire Middle Name Generation Suffix (Jr., I, II, etc.) Gender of Child: Male Female Lives with: Mother______ Father______ Both______ Other (please specify)________________________________ ____________________________________________________________________________________________________________ Address (mailing) City State County Zip Home Phone # (include area code) ____________________________________________________________________________________________________________ Address (residing – if different from above) City State County Zip Home Phone # (include area code) _____________________________________________________ E-Mail Birthdate:______________________Birthplace:___________________________________________________________________ Month/Day/Year City State Has your child ever attended one of the township schools? Yes_________ No_________ If yes, please circle which school: Birchwood Copeland Dennis O’Brien Dwyer Katharine Malone Stony Brook Do you have another child in one of our elementary schools? Yes_________ No_________ If yes, please circle which school: Birchwood Copeland Dennis O’Brien Dwyer Katharine Malone Stony Brook Student is transferring out of: _____________________________________________________________ Name of School _____________________________________________________________ Street, City, State, Zip _____________________________________________________________ Phone Number (include area code) Grade_______ General Education Program Yes_____ No_____ Grade ______ Is your child classified for Special Education & related services? Yes _____ No _______

If yes, what is your child’s classification? _______________________________________ What Special Education program(s) does your child attend? (i.e., In-class support, pull-out replacement resource, Language & Learning Disabilities (LLD), Preschool Disabilities, Behavioral Disabilities, Autism, Multiple Disabilities.) ____________________________________________________________________________________________________

PAGE 1 of 6

Complete ______ Incomplete ______

PARENT INFORMATION>>>>PLEASE CIRCLE EITHER PARENT OR STEPPARENT ____________________________________________________________________________________________________________ Father / Stepfather Address (include city, state, zip) ____________________________________________________________________________________________________________Father’s Home Phone # (include area code) Father’s Cell Phone # (include area code) ____________________________________________________________________________________________________________ Father Employed by Address (include city, state, zip) Phone # (include area code) ____________________________________________________________________________________________________________ Mother / Stepmother Address (include city, state, zip) ____________________________________________________________________________________________________________ Mother’s Home Phone # (include area code) Mother’s Cell Phone # (include area code) ____________________________________________________________________________________________________________ Mother Employed by Address (include city, state, zip) Phone # (include area code) ____________________________________________________________________________________________________________ Guardian (if applicable) Address (include city, state, zip) ____________________________________________________________________________________________________________ Guardian Home Phone # (include area code) Guardian Cell Phone # (include area code) ____________________________________________________________________________________________________________ Guardian Employed by Address (include city, state, zip) Phone # (include area code) Please place an “X” in the box indicating your child’s race/ethnic category: NOTE: If the parent/guardian objects to specifying his/her child’s ethnic code, it will be determined by the registrar.

Two or More Races, Non-Hispanic – A person having 2 races that are Non-Hispanic. If this category is selected, please check off which two races above.

White – A person having origins in any of the original peoples of Europe, Middle East or North Africa.

Black (African American) – A person having origins in any of the black racial groups of Africa. Terms such as “Haitian”

or “Negro” can be used in addition to “Black or African American.”

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand or Vietnam.

Spanish/Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish Culture or origin.

American Indian/Alaskan – A person having origins in any of the original Peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Hawaiian/Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

PAGE 2 of 6

Please place an “X” in the box indicating the Country of Birth of your child:

Afghanistan Cook Islands India Nauru South Georgia Is. Albania Costa Rica Indonesia Nepal Spain Algeria Croatia Isle of Man Netherlands Sri Lanka American Samoa Cuba Iran Netherlands Antilles Sudan Andorra Cyprus Iraq New Caledonia Suriname Angola Czech Republic Ireland New Zealand Svalbard Anguilla Israel Nicaragua Swaziland Antarctica Italy Niger Sweden Antigua & Barbuda Denmark Jan Mayen Nigeria Switzerland Argentina Djibouti Jamaica Niue Syria Armenia Dominica Japan Norfolk Island Taiwan Aruba Dominican Republic Jordan Northern Mariana Is. Tajikistan Australia Ecuador Kazakhstan Norway Tanzania Austria Egypt Kenya Oman Thailand Azerbaijan El Salvador Kiribati Pakistan Timor-Leste Bahamas Equatorial Guinea Korea, North Palau Togo Bahrain Eritrea Korea, South Palestine (West Bank) Tokelau Bangladesh Estonia Kuwait Panama Tonga Barbados Ethiopia Kyrgyzstan Papua New Guinea Trinidad & Tobago Belarus Falkland Islands Laos Paraguay Tunisia Belgium Faroe Islands Latvia Peru Turkey Belize Fiji Lebanon Philippines Turkmenistan Benin Finland Lesotho Pitcairn Is. Turks & Caicos Is. Bermuda Liberia Poland Tuvalu Bhutan France Libya Portugal Uganda Bolivia French Guiana Liechtenstein Puerto Rico Ukraine Bosnia & Herzegovina French Polynesia Lithuania Qatar Union of Soviet Soc. Botswana French Southern Ter. Luxembourg Reunion United Arab Emirates Bouvet Island Gabon Macau Romania United Kingdom Brazil Gambia Macedonia Russian Federation United States British Indian Ocean Georgia Madagascar Rwanda Brunei Malawi Saint Helena Uruguay Bulgaria Germany Malaysia Saint Kitts & Nevis Uzbekistan Burkina Ghana Maldives Saint Lucia Vanuatu Burundi Gibraltar Mali Saint Pierre & Miguel. Vatican City Byelorussian SSR Greece Malta Saint Vincent & Gren. Venezuela Cambodia Greenland Marshall Islands Samoa Vietnam Cameroon Grenada Martinique San Marino Virgin Islands Canada Guadeloupe Mauritania Sao Tome & Principe Wake Island Cape Verde Guam Mauritius Saudi Arabia Wallis & Futuna Cayman Islands Guatemala Mayotte Senegal Western Sahara Central African Rep. Guinea Mexico Serbia & Montenegro Yemen Chad Guinea-Bissau Moldova Seychelles Zaire Chile Guyana Monaco Sierra Leone Zambia China Haiti Mongolia Singapore Zimbabwe Christmas Island Heard & McDon. Isl. Montserrat Slovakia Cocos (Keeling) Is. Honduras Morocco Slovenia Colombia Hong Kong Mozambique Solomon Islands Comoros Hungary Myanmar (Burma) Somalia Congo Iceland Namibia South Africa

PAGE 3 of 6

Please place an “X” in the box indicating the language that your child first learned to speak at home:

Arabic Greek Korean Romanian Thai

Cantonese Gujarati Macedonian Russian Turkish

Chinese Hausa Malayalam Serbian Ukranian

English Hebrew Mandarin Spanish Urdu

Farsi Hindi Marathi Syrian Uzbek

Filipino Hungarian Persian Tagalog Vietnamese

French Italian Polish Tamel Other

German Japanese Portuguese Telugu Other When did your child first enroll in a US school? ______________ Does your child speak English? Yes__________ No__________ What language do you (his/her parents) use most often when speaking to your child at home?____________________________ What language does your child most often use when speaking to you (his/her parents)? ________________________________

YOUR SIGNATURE BELOW VERIFIES THAT ALL THE INFORMATION FILLED OUT, IN THIS REGISTRATION PACKET, IS ACCURATE AND CORRECT. __________________________________________________________________________________________ Parent/Guardian Name (please print) Parent/Guardian Signature Date

PAGE 4 of 6

HEALTH INFORMATION

PLEASE PRINT ALL INFORMATION Student Name (Last Name, First Name)__________________________________________________Grade__________________

What was the date (month/day/year required) of your child’s last physical? ___________________________________________ Month/Day/Year Is your child covered by health insurance? Yes_____ No_____ If yes, what is the name of your insurance company:_______________________________________________________________ Does your child receive treatment for: Diabetes_____ Heart Condition_____ Asthma_____ Is an inhaler prescribed?_____ Seizure Disorder_____ Other_____________________________________________ Please indicate if your child has any allergies to: Peanuts_____, Milk_____, Eggs_____, List Other Foods______________ __________________________, Latex_____, Bee Stings_____, Other Allergies (please give details)________________________ ___________________________________________________________________________________________________________ Has your physician prescribed an EpiPen for treatment of this allergy? Yes_____ No_____ Has he/she ever received Adrenaline for treatment of an allergy? Yes_____ No_____ If yes, when?__________________________________ Month/Day/Year Is your child receiving treatment for any medical condition(s) not listed? Yes_____ No_____ If yes, please give details______________________________________________________________________________________ ___________________________________________________________________________________________________________ Has your child had any contagious diseases? If so, please specify and include an approximate date: _______________________________ Date__________ _______________________________ Date__________ Is your child currently taking any prescribed medication? Yes_____ No_____ If yes, please specify what medication, the dose, and when and how often it is administered______________________________ ___________________________________________________________________________________________________________ Has your child been tested for Lead? Yes_____ No_____ If yes, please indicate date (month/day/year required) and the level of lead____________________________________________ Month/Day/Year Lead Level Does your child use: Glasses/Contacts_____ Hearing Aid(s) _____ Any Other Physical Aids_____ If checked, Please indicate what type of physical aid(s)_______________________________________________________________________ ___________________________________________________________________________________________________________ List surgeries, illnesses, injuries (fractures, head injury, etc.) or previous hospitalizations:_______________________________ ____________________________________________________________________________________________________________

Please contact the school nurse if your child will be needing medications, treatments, or has special needs so that the school can properly prepare the Health Office to meet those needs

PAGE 5 of 6

Page 6 of 6

PAGE 6 of 6

Page 6 of 6 EMERGENCY CARE FOR INJURIES AND/OR SUDDEN ILLNESSES In the event that a child requires emergency care for injuries, sudden illnesses or needs to be sent home because of illness, the parent/guardian is contacted immediately. Please list below the names, addresses and telephone numbers of 2 neighbors or relatives we can contact in case the parents/guardian cannot be reached at home, work or by cell: ____________________________________________________________________________________________________________ Name Home Phone # Cell Phone # Relationship to Student (include area code) (include area code) ____________________________________________________________________________________________________________ Name Home Phone # Cell Phone # Relationship to Student (include area code) (include area code) ____________________________________________________________________________________________________________ Family Physician’s Name Address (city, state, zip) Phone # (include area code) Name of hospital the child can be taken to for emergency treatment when we are unable to contact you: ____________________________________________________________________________________________________________ Hospital Address (city only) Phone # (include area code) PLEASE SIGN BELOW TO INDICATE THAT WE HAVE YOUR PERMISSION TO CALL THE PHYSICIAN LISTED OR TO TAKE YOUR CHILD TO THE DESIGNATED HOSPITAL. YOUR SIGNATURE ALSO VERIFIES THAT ALL THE HEALTH INFORMATION GIVEN IS ACCURATE AND CORRECT. __________________________________________________________________________________________ Parent/Guardian Name (please print) Parent/Guardian Signature Date

ROCKAWAY TOWNSHIP PUBLIC SCHOOLS REPORT OF KINDERGARTEN

PHYSICAL EXAMINATION

PARENTS: PLEASE HAVE YOUR FAMILY PHYSICIAN COMPLETE THIS PHYSICAL EXAMINATION REPORT AND BRING IT WITH YOU TO

KINDERGARTEN REGISTRATION

THIS EXAMINATION SHOULD BE COMPLETED AFTER SEPTMBER 6, 2016 AND BEFORE THE START OF SCHOOL SEPTEMBER 7, 2017.

Date of Birth ________________________ ________________________________________________________________________ Child’s Last Name First Middle Address City State Zip Code ________________________________________________________________________ Parents/Guardian Name Telephone Number _______________________________________________________ Physician Name _________________________________________________________ Address ________________________________________________________________ Telephone Number _______________________________________________________ Signature of Examining Physician __________________________________________ Date of Examination _____________________________________________________ Physical Status: Height ____________ Weight ___________ Blood Pressure_____________

1

PLEASE WRITE WNL (Within Normal Limits) OR COMMENT ON THE FOLLOWING AREAS: Nose Spine Throat Chest Gums Heart Teeth Lungs Ears – Hearing Aid Required? Abdomen Eyes – Glasses Required? Genitals Scalp Nutrition Skin Habits Posture Glands Feet Speech Other Defects: Were there any problems during the prenatal period or with the birth? ________________________________________________________________________ ________________________________________________________________________ Describe any past or present medical conditions: Allergies _______________________________________________________________ Asthma ________________________________________________________________ Diabetes _______________________________________________________________ Heart Murmur __________________________________________________________ Seizure Disorder _________________________________________________________ History of Significant Illness_______________________________________________ Hospitalizations _________________________________________________________ Surgery ________________________________________________________________ Medications taken on a daily or as needed basis _______________________________ ________________________________________________________________________ May participate in all activities without restrictions: Yes ______ No _____ List restrictions: ___________________________________________________ _______________________________________________________________________ Other: _________________________________________________________________ Please attach a COMPLETE immunization schedule or fill in the dates on the enclosed immunization schedule. Rev. 2/15 2

Record of Immunizations: (Fill in dates) 1. DPT Immunization 1St Injection ____________ 2nd Injection ____________ 3rd Injection ____________ 4th Injection ____________ (Must be given on or after the 4th birthday) 2. O.P.V. or IPV (Please specify which) 1st ______________ 2nd _____________ 3rd _____________ 4th (Not Required) _____________ (1 dose must be given on or after the 4th birthday if only 3 doses are given or ANY 4 doses are accepted.) 3. MMR 1. ________________________________________________________________ (Must be on or after the 1st birthday) 2. ________________________________________________________________ (A 2nd dose of a measles containing vaccine, preferably MMR, required for children born on or after January 1, 1990.) PLEASE NOTE: MMR Replaces #4, 5 & 6 4. Measles Vaccine (live) __________________________________________________ (Must be on or after the 1st birthday) ______________________________________________ (2nd dose) 5. Rubella Vaccine (live) __________________________________________________ (Must be on or after the 1st birthday) 6. Mumps Vaccine (live) __________________________________________________ (Must be on or after the 1st birthday) 7. Hepatitis B 1st Injection ____________________ 2nd Injection ____________________ 3rd Injection ____________________ 8. Pneumococcal __________________________________________________________ (1 dose after the 1st birthday for children starting Kindergarten under the age of 5.) 9. HIB ___________________________________________________________________ (1 dose after the 1st birthday for children starting Kindergarten under the age of 5.) 10. Varicella _______________________________________________________________ (1 dose on or after the 1st birthday) 11. Mantoux (May be required for students born outside of the US, entering a school system for the 1st time unless done at age 3 or older_________________________ 12. Other __________________________________________________________________

TRANSPORTATION DEPARTMENT

KINDERGARTEN NEW STUDENT INFORMATION

Student ID# STUDENTS NAME Last First Middle STUDENT’S ADDRESS Street Apt # City/Town State Zip Code TELEPHONE NUMBER BIRTHDATE MALE FEMALE ENTERING GRADE SCHOOL ATTENDING START DATE REMARKS (BABY-SITTING PICKUP IF OTHER THAN HOME) A.M. P.M.

BUS INFORMATION

PICK UP TIME ROUTE # STOP LOCATION BUS STOP MOTHER’S NAME FATHER’S NAME NAME OF LAST SCHOOL OR LOCATION PREPARED BY DATE

Child Care Provider Forms must be renewed each year for bus scheduling purposes. Parents wishing to have their child/children transported to and from a child care provider must complete this form and return it to the Transportation Department located at 540 Green Pond Road, Rockaway, 07866 by the last day of the school year. The child care provider must be within the student’s home school district. If during the school year you need to send your child/children to and from a child care provider, you must go to your child/children’s school(s) and fill out a Child Care Provider Form. All bus changes take 48 hours to process. Once bus assignments have been completed and the bus passes are printed, changes become complicated. Waiting until September to make arrangements to have your child ride the school bus to and from a child care provider could result in having your request denied because that particular bus is full. Forms received the first week of school will not be implemented until the second week of school.

It is the practice of the Rockaway Township Board of Education that all students are assigned to only one bus. Students must be picked up and / or dropped off at the same bus stop everyday. Busing to a child care provider can only occur if the provider lives within the boundaries of the school which the child/children attend. Please call the Transportation Office at 973-627-3377 with any questions or concerns.

I would like to have my child/children listed above picked up and / or returned to:

NAME OF CHILD CARE PROVIDER

PROVIDER’S

TELEPHONE NUMBER

PROVIDER’S

ADDRESS DATE EFFECTIVE

he above named is acting as a child care provider for my children during the working day.

Signature of Parent/Guardian:_____________________________________Date:_____________ Phone Number (home):____________________________(work):_________________________ Address:_______________________________________________________________________ OFFICE USE ONLY Approval:____________ Date:_________________ Bus Number:__________________

NAME OF CHILD/CHILDREN GRADE SCHOOL

CHILD CARE PROVIDER FORM 2017-2018