Student Registration PDF · •...
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Transcript of Student Registration PDF · •...
!!!!!Dear!Parents,!
SUMMIT&PUBLIC&SCHOOLS!Summit,&New&Jersey!
PRIMARY&&CENTER&®ISTRATION&&INFORMATION!
!
Welcome!to!the!Primary!Centers.! As!you!begin!the!registration!process,!know!that!we!are!here!to!support!!!you!at!every!step.! Below!you!will!find!key!pieces!of!information!to!guide!you!through!this!process.! It!is!important!to!follow!all!the!steps!outlined!to!ensure!we!have!accurate!information!to!serve!your!child!and!you.!In!this!packet!you!will!find!the!following!items:!
!
• Primary'Centers'Fact'Sheet!• Preliminary'' Information!• Check'List*!• Residency'Verification'Form*!• Certification'of'Property'Owner'or'Landlord*!• Student'Registration'Form*!• Health'History'Questionnaire*!
• Medical'Guidelines'&'Immunizations!• Medical'Evaluation'Form*!• Publicity'Consent'Form*!• Parent'Survey*!• AM/PM'Session'Request'Form*!• School'Information'Form'*!• Home'Language'Survey*!
!!Where&and&When&to&Register:!Registration&for&Preschool&will&take&place&on&January&25&&&26,&2016&at&Jefferson&Primary&Center.&Registration&for&Full&Day&Kindergarten&will&take&place&on&January&20,&21&&&22,&2016&at&the&Primary&Center&your&child&will&attend.&&Regular&½&Day&Kindergarten&Registration&will&take&place&on&February&4&&&5,&2016&at!the!Primary!Center!your!child!will!attend.! To!schedule!an!appointment,!please!call!the!following!school!secretaries:!&
Jefferson!Primary!Center:! Eileen!Mortenson! (908)!918^2160!x!6752!Wilson!Primary!Center:!!! Judy!Shulze! (908)!918^2175!x!6652!
!If!you!are!a!kindergarten!parent!and!are!not!sure!which!Primary!Center!your!child!will!attend,!you!may!call!either!of!the!Primary!Centers!or!the!Summit!Board!of!Education!at!(908)!918^2100!x!3102!for!further!information.!If!you!are!a!Preschool!parent,!please!note!that!the!Office!of!Special!Services!administers!Preschool!placement!decisions.!They!can!be!reached!at!908^273^6658.!
!
What&to&Bring&to&Registration:!• *Required!forms!(see#above)!• Residency!Verification!and!Proof!of!
Residency!documents!(see#Preliminary#Information#Form)!
!!• Original!birth!certificate!with!raised!seal!
or!current!Passport!• Immunization!Record!
!
Once!you!have!reviewed!the!forms,!if!you!have!any!question!as!to!how!to!complete!them,!please!contact!your!Primary!Center!secretary!listed!above.!This!will!help!avoid!an!instance!of!incomplete!paperwork!which!may!make!it!necessary!to!re^schedule!registration!to!a!later!date!when!you!can!provide!all!the!required!forms.! The!only!exception!to!this!rule!is!the!*Medical'Evaluation'form,!which!needs!to!be!submitted!by!June!1,!2016,!if!!the!information!is!not!obtained!by!the!registration!date.!!We!look!forward!to!working!with!you!to!assure!a!successful!experience!in!the!Summit!Public!Schools.! There!will!be!many!opportunities!for!the!new!students!to!become!familiar!with!the!centers.! In!the!early!spring,!we!will!host!an!Open!House!where!new!students!will!visit!a!teacher!and!walk!through!one!of!our!classrooms.! It!is!all!in!preparation!for!the!big!day!coming!next!September.! Between!now!and!then,!again,!we!are!here!to!support!you.!Please!contact!us!at!any!time.!!Sincerely,!
Janice!Tierney!Principal
!The&Primary&Center&at&Jefferson&&The&Primary&Center&at&Wilson&
Fact&Sheet!!The&Primary&Center&Program&The!Primary!Centers!at!Jefferson!and!Wilson!offer!a!unique!opportunity!for!students,!ages!3! ^! 6,! to! participate! in! a! program! that! is! designed! specifically! for! their! age! ! group.! ! The!schools! are! designed! for! primary!aged! students! with! each! spacious! classroom! equipped!with! a! bathroom! and! access! to! the! outdoors.! In! addition,! a! large! multipurpose! room! is!available! for! physical! education,! library,! assemblies! and! parent! programs.! All! teachers!employed! in! the!Primary!Centers!have!been! trained! in!early! childhood!development!and!instructional!strategies!as!well!as!balanced!literacy.!The!curriculum!is!designed!to!develop!the!skills!and!knowledge!base!necessary!for!students!to!transition! into!the!approved!first!grade!program.!
!The&Program&The!Primary!Center!program!follows!curriculum!approved!by!our!district!in!literacy,!math,!social! studies,! and! science.! Strategies! such! as! cooperative! learning! and! differentiated!instruction!are!employed!to!ensure!that!the!needs!of!each!student!are!addressed!within!the!instructional! program.! Enriched! literacy! opportunities,! physical! education,! and! the!integration!of!technology!in!classroom!are!part!of!regular!activities.!
!Schedule&The!opening!and!closing!times!of!the!Primary!Centers!were!established!to!provide!parents!with!time!for!multiple!student!drop!offs!at!an!elementary!school!and!at!a!Primary!Center.!For!all!but!a!limited!number!of!specialized!programs,!the!school!hours!are!as!follows:!
!!!AM&Kindergarten&Program! ! PM&Kindergarten&Program!
Drop!Off! 8:15!to!8:30! ! Drop!Off! 12:15!to!12:22!Instruction!Time! 8:30!to!11:22! ! Instruction!Time! 12:22!to!3:15!
Pick!Up! 11:22! ! Pick!Up! 3:15!!!Full&Day&Kindergarten&Program!
Drop!Off! 8:15!to!8:30!Instruction!Time! 8:30!to!3:15!
Pick!Up! 3:15!!!AM&Preschool&Program! ! PM&Preschool&Program!
Drop!Off! 8:50!to!9:00! ! Drop!Off! 12:20!to!12:30!Instruction!Time! 9:00!to!11:30! ! Instruction!Time! 12:30!to!3:00!
Pick!Up! 11:30! ! Pick!Up! 3:00!
SUMMIT&PUBLIC&SCHOOLS&Preliminary&Information&
&PRELIMINARY&INFORMATION:&&PLEASE&READ&BEFORE&PROCEEDING&
&The&questions&asked&in&the&following&pages&will&enable&us&to&determine&your&student's&eligibility&to&attend&school&in&this&district&in&accordance&with&New&Jersey&law.&&Please#be#aware#that#N.J.S.A.#18A:38@1#and#N.J.A.C.#6A:22#require#that#a#free#public#education#be#provided#to#students#between#the#ages#of#5#and#20,#and#to#certain#students#under#5#and#over#20#as#specified#in#other#applicable#law,#who#are:##
• Domiciled#in#the#district,#i.e.,#living#with#a#parent#or#guardian#whose#permanent#home#is#located#within#the#district.##A#home#is#permanent#when#the#parent#or#guardian#intends#to#return#to#it#when#absent#and#has#no#present#intent#of#moving#from#it,#notwithstanding#the#existence#of#homes#or#residences#elsewhere#
#• Living#with#a#person,#other#than#the#parent#or#guardian,#who#is#domiciled#in#the#district#and#is#
supporting#the#student#without#compensation,#as#if#the#student#were#his#or#her#own#child,#because#the#parent#cannot#support#the#child#due#to#family#or#economic#hardship#
#• Living#with#a#person#domiciled#in#the#district,#other#than#the#parent#or#guardian,#where#the#
parent/guardian#is#a#member#of#the#New#Jersey#National#Guard#or#the#reserve#component#of#the#U.S.#armed#forces#and#has#been#ordered#into#active#military#service#in#the#U.S.#armed#forces#in#time#of#war#or#national#emergency#
#• Living#with#a#parent#or#guardian#who#is#temporarily#residing#in#the#district#
#• The#child#of#a#parent#or#guardian#who#moves#to#another#district#as#the#result#of#being#homeless#
#• Placed#in#the#home#of#a#district#resident#by#court#order#pursuant#to#N.J.S.A.#18A:38:2#
#• The#child#of#a#parent#or#guardian#who#previously#resided#in#the#district#but#is#a#member#of#the#New#
Jersey#National#Guard#or#the#United#States#reserves#and#has#been#ordered#to#active#service#in#time#of#war#or#national#emergency#pursuant#to#N.J.S.A.#18A:38:3(b)#
#• Residing#on#federal#property#within#the#State#pursuant#to#N.J.S.A.#18A:38:7.7#et#seq.#
#Note#that#the#following#do#not#affect#a#student's#eligibility#to#enroll#in#school:##
• Physical#condition#of#housing#or#compliance#with#local#housing#ordinances#or#terms#of#lease##
• Immigration/visa#status,#except#for#students#holding#or#seeking#a#visa#(F:1)#issued#specifically#for#the#purpose#of#limited#study#on#a#tuition#basis#in#a#United#States#public#secondary#school#
#• Absence#of#a#certified#copy#of#birth#certificate#or#other#proof#of#a#student's#identity,#although#these#
must#be#provided#within#30#days#of#initial#enrollment#pursuant#to#N.J.S.A.#18A:36:25.1##
• Absence#of#student#medical#information,#although#actual#attendance#at#school#may#be#deferred#as#necessary#in#compliance#with#rules#regarding#immunization#of#students,#N.J.A.C.#8:57:4.1#et#seq.#
#• Absence#of#a#student's#prior#educational#record,#although#the#initial#educational#placement#of#the#
student#may#be#subject#to#revision#upon#receipt#of#records#or#further#assessment#by#the#district######&
PRELIMINARY&INFORMATION&(CONTINUED)&&
The&following&forms&of&documentation&may&demonstrate&a&student's&eligibility&for&enrollment&in&the&district.&&Particular&documentation&necessary&to&demonstrate&eligibility&under&specific&provisions&in&law&will&be&indicated&in&the&appropriate§ion&of&the®istration&form.&&PROOF&OF&RESIDENCY:&#
• Property#tax#bills,#deeds,#contracts#of#sale,#leases,#mortgages,#signed#letters#from#landlords#and#other#evidence#of#property#ownership,#tenancy#or#residency&
&SUPPORTING&DOCUMENTS&(MUST&SHOW&ADDRESS&OF&RECORD):&&
• Voter#registrations,#licenses,#permits,#financial#account#information,#utility#bills,#delivery#receipts,#and#other#evidence#of#personal#attachment#to#a#particular#location#
#• Court#orders,#State#agency#agreements#and#other#evidence#of#court#or#agency#placements#or#
directives##
• Receipts,#bills,#cancelled#checks#and#other#evidence#of#expenditures#demonstrating#personal#attachment#to#a#particular#location,#or,#where#applicable,#to#support#of#the#student#
#• Medical#reports,#counselor#or#social#worker#assessments,#employment#documents,#benefit#
statements,#and#other#evidence#of#circumstances#demonstrating,#where#applicable,#family#or#economic#hardship,#or#temporary#residency#
#• Affidavits,#certifications#and#sworn#attestations#pertaining#to#statutory#criteria#for#school#attendance,#
from#the#parent,#legal#guardian,#person#keeping#an#"affidavit#student,"#adult#student,#person(s)#with#whom#a#family#is#living,#or#others#as#appropriate#
#• Documents#pertaining#to#military#status#and#assignment#
#• Any#business#record#or#document#issued#by#a#government#entity#
#• Any#other#form#of#documentation#relevant#to#demonstrating#entitlement#to#attend#school#
#You#will#not#be#asked#for#any#information#or#document#protected#from#disclosure#by#law,#or#pertaining#to#criteria#which#are#not#legitimate#bases#for#determining#eligibility#to#attend#school.##You#may#voluntarily#disclose#any#document#or#information#you#believe#will#help#establish#that#the#student#meets#the#requirements#of#law#for#entitlement#to#attend#school#in#the#district,#but#we#may#not,#directly#or#indirectly,#require#or#request:##
• Income#tax#returns##
• Documentation#or#information#relating#to#citizenship#or#immigration/visa#status,#unless#the#student#holds#or#is#applying#for#an#F:1#visa#
#• Documentation#or#information#relating#to#compliance#with#local#housing#ordinances#or#conditions#of#
tenancy##
• Social#security#numbers##Please&be&aware&that&any&initial&determination&of&the&student's&eligibility&to&attend&school&in&this&district&is&subject&to&more&thorough&review&and&subsequent&re^evaluation,&and&that&tuition&may&be&assessed&in&the&event&that&an&initially&admitted&student&is&later&found&ineligible.&&If&your&student&is&found&ineligible,&now&or&later,&you&will&be&provided&the&reasons&for&our&decision&and&instructions&on&how&to&appeal.&
If'you'experience'difficulties'with'the'enrollment'process,'please'see'the''Building'Principal'for'assistance'
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#1&
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SUMMIT&PUBLIC&SCHOOLS&
Checklist&
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Student&Name:&______________________________________________________________________________________&
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Parent/Guardian&Submitting&Form:&_____________________________________________________________&
#Please#feel#free#to#use#this#checklist#as#an#organizational#tool#by#checking#off#the#items#you#have#collected#and#bring&this&checklist&to&your®istration&appointment.##Reserve#the#shaded#areas#identified#for#Office&Use.##All#forms#are#attached.#
#Form&#& Title& Office&Use&
1# o Check'List' #2# o Residency'Verification'Form' #3# o Certification'of'Property'Owner'or'
Landlord'Form'#
4# o Student'Registration'Form' #5# o Health'History'Questionnaire'Form# #6# o Medical'Evaluation'Form'(due'June'1st)' #7# o Publicity'Consent'Form' #8# o Parent'Survey'Form' #9# o AM/PM'Session'Request'Form' #10# o School'Information'Form' #11# o Home'Language'Survey' #
#Proof&of&Residency&(1&required):&
&
& Homeowner:&
o Deed# #o Mortgage#Statement# # #o Tax#Bill##
Tenant:#o Lease# #
# #AND' '
o 3&supporting&proofs&showing&name&and&address#–#this#may#include#voter#registration#card,#licenses,#permits,#financial#statements,#utility#bills,#delivery#receipts#–#see#Preliminary#Information#sheet#for#complete#list#of#items.#
###For&Office&Use&–&Do¬&write&below&this&line.&
Utility#Bills#############Licenses################Financial#Statements################Bills###################Court#Orders#Agency####################Receipts###################################Voter#Registration#
#2&SUMMIT&PUBLIC&SCHOOLS&Residency&Verification&Form&
&RESIDENCY&VERIFICATION&FORM&
#To#the#Person#Enrolling#the#Student:##Below#is#Section&A#of#the#RESIDENCY&VERIFICATION&FORM,#which#must#be#completed#and#returned#with#your#registration#packet.#This#section#is#intended#for#students'living'with'a'parent'or'guardian#whose#permanent'home#is#the#address#given#on#the#registration#form,#and#address#located'in'the'district'of'Summit,'New'Jersey.#####If#you#are#registering#a#student#for#whom#you#are#not#the#parent#or#guardian,#a#student#who#is#temporarily#residing#in#the#district,#or#in#other#circumstances,#you#may#need#to#complete#forms#referred#to#as#Section'B,'Section'C,'or'Section'D.##If#you#believe#this#is#that#case#for#the#student#you#are#registering,#please#speak#with#the#school#secretary.##If#you#are#the#student's#guardian,#or#will#be#the#guardian#of#a#student#from#out#of#state#following#expiration#of#the#required#6@month#waiting#period,#you#will#be#asked#to#provide#official#papers#proving#guardianship.#&SECTION&A&(DOMICILE):&&Complete#this#section'if'the'student'is'living'with'a'parent'or'guardian#whose#permanent'home#is#the#address#given#on#the#registration#form#and#is#located'in'the'district.##
Name&of&Student:& & & & & & & & & & & &
Name&of&Parent/Guardian&Enrolling&the&Student:& & & & & & & &
How#long#have#you#lived#in#this#home?____________________________________________________________# #
Do#you#have#any#present#intention#of#moving#from#this#home?##If#so,#when#and#to#where?#
_________________________________________________________________________________________________________# # #
Do#you#have#residences#elsewhere,#and,#if#so,#where#are#they#and#when#do#you#live#there?#
_________________________________________________________________________________________________________# # #
Please#list#the#proof#of#residency#document#and#three#supporting#documents#(see#page#2#of#Preliminary#Information#included#in#this#packet)#you#will#provide#to#demonstrate#that#the#address#given#on#the#registration#form#is#your#permanent#home:###1.# # # # # # # # # # # # # #
2.# # # # # # # # # # # # # #
3# # # # # # # # # # # # # #
4.# # # # # # # # # # # # # #
#Signature&of&Parent/Guardian:& & & & & &Date:& & & & &&If'the'student's'parents'are'domiciled'in'different'districts,'regardless'of'which'parent'has'legal'custody,'please'answer'the'following'questions:'#Is#there#a#court#order#or#written#agreement#between#the#parents#designating#the#district#for#school#attendance,#and#if#so,#where#does#it#require#the#student#to#attend#school?##(You#will#be#asked#to#provide#a#copy#of#this#document.)___# # # # #
###
RESIDENCY&VERIFICATION&FORM&(CONTINUED)&&SECTION&A&(DOMICILE)&CONTINUED:##Does#the#student#reside#with#one#parent#for#the#entire#year?##If#so,#with#which#parent#and#at#
what#address?_________________________________________________________________________________________## #
_________________________________________________________________________________________________________# # #
If#not,#for#what#portion#of#time#does#the#student#reside#with#each#parent#and#at#what#
addresses?____________________________________________________________________________________________# # #
_________________________________________________________________________________________________________# # #
If#the#student#lives#with#both#parents#on#an#equal:time,#alternating#week/month#or#other#similar#basis,#with#which#parent#did#the#student#reside#on#the#last#school#day#prior#to#October#16#preceding#the#date#of#this#application?________________________________________________##Please'note:##No#district#is#required,#as#a#result#of#being#the#district#of#domicile#for#school#attendance#purposes#where#a#student#lives#with#more#than#one#parent,#to#provide#transportation#for#a#student#residing#outside#the#district#for#part#of#the#school#year,#other#than#transportation#based#upon#the#home#of#the#parent#domiciled#within#the#district#to#the#extent#required#by#law.##If#you#are#claiming#to#be#an#emancipated#student,#are#you#living#independently#in#your#own#permanent#home#in#the#district?##If#yes,#please#describe#the#proofs#you#will#provide,#in#addition#to#those#demonstrating#domicile,#to#demonstrate#that#your#are#not#in#the#care#and#custody#of#a#parent#or#legal#guardian._______________________________________________________________##_________________________________________________________________________________________________________##_________________________________________________________________________________________________________##Please#note:##Under#New#Jersey#law,#where#a#dwelling#is#located#within#two#or#more#local#school#districts,#or#bears#a#mailing#address#that#does#not#reflect#the#dwelling's#physical#location#within#a#municipality,#the#district#of#domicile#for#school#attendance#purposes#is#that#of#the#municipality#to#which#the#resident#pays#the#majority#of#his#or#her#property#tax,#or#to#which#the#majority#of#property#tax#for#the#dwelling#in#question#is#paid#by#the#owner#of#a#multi@unit#dwelling.#
&END&OF&SECTION&A&
&& &
& & & & & & & & & & & & #3&SUMMIT&PUBLIC&SCHOOLS&
Summit,&New&Jersey&&
CERTIFICATION&OF&PROPERTY&OWNER&OR&LANDLORD&&#___________________________________________#
# # # # # ########## # ##########(Date)#To#The#Summit#Board#of#Education:##This#is#to#state#that#I,#__________________________________________________________,#am#the#
landlord#or#owner#of#the#property#located#at______________________________________________#
_________________________________________________________________________________________________#
This#is#to#further#state#that#the#following#persons#reside#at#the#above#address#(list#first#and#last#names#of#all#family#members):#
___________________________________________________________________#
____________________________________________________________________#
____________________________________________________________________#
____________________________________________________________________#
Date#family#moved#into#my#residence#_____________________________________________________#
I#certify#that#the#foregoing#statements#are#true.##I#am#aware#that#if#any#of#the#foregoing#statements#made#by#me#are#willfully#false,#I#am#subject#to#punishment.##If#this#arrangement#changes,#it#is#my#obligation#to#notify#the#Board#of#Education.### # # # # Sincerely,#
#
# # # # # _________________________________________________## # # # # (Signature)##Sworn#and#subscribed#to#before#me#this________________day#of___________________,#20___##______________________________________________#(Signature#of#School#Official#or#Notary)##~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~##Documentation#Provided#(one#Proof#of#Residency#&#three#Supporting#Documents):#Proof#of#Residency:# ________#property#tax#bill################# # # ________#mortgage,#deed,#contract#of#sale,#lease## # # # #Supporting#Documents:# ________#driver's##license## # # ________#voter#registration#card## # # ________#utility#bill,#permit,#financial#account#information## # # ________##receipt,#bill,#cancelled#check## # # ________#other#(describe)#___________________________________##11/2010#
! ! ! ! ! ! ! ! ! ! ! ! ! #!4! !!!SUMMIT!PUBLIC!SCHOOLS!STUDENT!REGISTRATION!FORM!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!This%information%is%to%be%completed%by%school%staff:%School%ID_______________________________Student%ID__________________________________State%Student%ID_________________________%Grade___________Counselor_____________________________________Start%Date_________________________Homeroom_______________%!STUDENT!INFORMATION%(Please%Print):!!!!!!!!!!!!!!!!!!Gender%(please%circle):%%%%Female%%%%%% Male%%
Last%Name:% % % % First%Name:% % % % %Middle%Name:% % % % %
Preferred%Name:% % % %
Street:% % % % % % %Apt.%#% % City% % % State% % Zip% % %
Home%Phone:% % % % % Date%of%Birth:% % % % %
Birthplace:%%City:% % % % State:% % % Country:% % % % %
%Race/Ethnicity%(the%State%of%New%Jersey%requires%we%report%this%information;%please%circle%all%those%that%apply):% %
%White% %% %Black% % %Hispanic% %%%%%%%American%Indian/Alaskan%Native% %%%%%Asian%% Pacific%Islander%%%
%
Multiracial%(circle%above%all%those%that%apply)% Primary!language%spoken%at%home:% % % % %
%CUSTODIAL!PARENT/GUARDIAN!!INFORMATION:!!F!check!one!F![!!]!Mother!![!!]!!Father!![!!]!!Guardian%
Name:% % % % % % %%%%%%If!Guardian,!relationship!to!Child:! ! ! ! !
%Relationship%Status%(circle%one):%%Married%%%%%%%Partnered%%%%%Divorced%%%%Widowed%%%%%%Separated% %%%%Single%
Street:% % % % % % Apt.%#% _____City:% % % State:% % Zip:% % %
Home%Phone:% % % % % % Work%Phone:% % % % % % %
Cell%Phone:% % % % % % EOmail%Address:%% % % % % %
Employer:% % % % % % City,%State,%Zip:% % % % % % % %
CUSTODIAL!PARENT/GUARDIAN!!INFORMATION:!F!check!one!F![!!]!Mother!![!!]!!Father!![!!]!!Guardian%
Name:% % % % % % %%%%%%%%If!Guardian,!relationship!to!Child:! ! ! ! !!
%%%Relationship%Status%(circle%one):%%Married%%%%%%%Partnered%%%%%Divorced%%%%Widowed%%%%%%Separated% %%%%Single%
Street:% % % % % % Apt.%#% _____City:% % % State:% % Zip:% % %
Home%Phone:% % % % % % Work%Phone:% % % % % % %
Cell%Phone:% % % % % % EOmail%Address:%% % % % % %
Employer:% % % % % % City,%State,%Zip:% % % % % % % %
NONFCUSTODIAL!PARENT/GUARDIAN!!!INFORMATION!if%applicable):!F!check!one!F![!!]!Mother!![!!]!!Father!![!!]!!Guardian!
Requires%duplicate!mailing%of%report%cards%and%progress%reports?%% [!!!]!Yes!!!!![!!!]!No%%%%
Name:% % % % % % !!!!!!!If!Guardian,!relationship!to!Child:% % % % %
%
Street:% % % % % % Apt.%#% _____City:% % % State:% % Zip:% % %
Home%Phone:% % % % % % Work%Phone:% % % % % % %
Cell%Phone:% % % % % % EOmail%Address:%% % % % % %
Employer:% % % % % % City,%State,%Zip:% % % % % % %
%
Is%there%any%legal!restriction%on%the%release%of%information?%[!!!]!Yes!![!!!]!No!!(If%yes,%please%provide%documentation)%% ! %
%(continued%on%back)%
Emergency!Contact!Information:!!Parents/Guardians%are%called%first;%if%unavailable,%persons%listed%below%will%be%called%for%authorization%of%medical%treatment/decisions.%
!1.%Name:% % % % % Phone:% % % % Cell%Phone:% % % % %
2.%Name:% % % % % Phone:% % % % Cell%Phone:% % % % %
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Emergency!Release!Information:!Parents/Guardians%are%called%first;%if%unavailable,%persons%listed%below%are%authorized%to%collect%your%child%from%school%in%the%event%of%an%extraordinary%emergency%or%early%closings.%
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2.%Name:% % % % % Phone:% % % % Cell%Phone:% % % % %
3.%Name:% % % % % Phone:% % % % Cell%Phone:% % % % %
To%prepare%for%such%emergencies,%discuss%with%your%child%those%you%list%as%authorized%to%collect%him/her%from%school.%
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NJ%SMART%–%State%Required%Health%Information%
The%New%Jersey%Department%of%Education%has%joined%with%the%New%Jersey%Department%of%Human%Services%to%identify%uninsured%
children%in%an%effort%to%improve%the%health%status%of%the%children%we%serve.%%As%part%of%this%initiative,%your%child’s%school%is%now%
required%to%report%on%the%health%status%of%all%of%their%students.%
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Health!Insurance!Status%(please%circle):%% % Yes%%(child%is%covered%by%health%insurance%
% % % % % % No%%%(child%is%not%covered%by%health%insurance)%
Health!Insurance!Provider:%(complete%name%of%insurer%without%abbreviation):_________________________________________________%%
________________________________________________________%% ________________________________________%
Signature%of%Parent/Legal%Guardian% % % % Date!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!The!remaining!information!is!to!be!completed!by!a!school!staff!member!The%following%information%has%been%received%and%has%been%verified%as%required%by%Policy.%%Copies%of%the%items%marked%with%a%√%must%be%attached%to%this%form.%%Additional%proof%may%be%required%in%accordance%with%Policy.%
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√(%%)%Official%proof%of%birth%(birth%certificate%must%have%raised%seal)%√(%%)%Four%items%proving%residency%(lease,%deed%or%mortgage%statement;%utility%bills,%driver's%license,%tax%bill%or%voter's%registration,%etc.)%√(%%)%Immunization%records%√(%%)%Signed%request%for%school%records%or%transfer%card%%
_______________________________________________________________________%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%______________________________________________%
Signature%of%School%Staff%Member%processing%this%Record% % % %%%%%%%%%Date%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Did%your%child%attend%PreK?%[!!!]!Yes!!!!![!!!]!No%%%%%%1%Year%_________%%2%Years%______________%%%Program%Name:__________________________________%%
Did%your%child%attend%Kindergarten?%[!!!]!Yes!!!!![!!!]!No%%%%%%Full%Day%_____%%Half%Day%_____%%%Program%Name:__________________________________%%
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& & & & & & & & & & & & #5&SUMMIT&PUBLIC&SCHOOLS
Health&History&Questionnaire #Dear#Parent/#Legal#Guardian:#We#would#like#your#child#to#gain#the#most#from#his/her#school#experience.#The#following#information#will#help#the#school#nurse#better#understand#your#child,#and#assist#in#the#transition#to#school.##If#your#child#has#a#special#health#care#concern#that#will#require#further#conversation,#please#call#the#school#nurse#to#schedule#a#meeting.##Student’s&Name__________________________________________#Birth&date__________________##Pregnancy/Birth&History:#Full#term#pregnancy:##Yes#(##)##No(##)#####Complications#of#delivery:#Yes#(##)#No#(##)###If#yes,#explain# # # # # # # # # # # # ##Was#there#any#medical#concerns#immediately#after#birth:#Yes#(##)#No#(##)####If#yes,#explain# # # # # # # # # # # # ##
&Developmental&History:#(circle#the#one#that#applies)#Sat#alone:## # early# # average# area#of#concern*#Crawled:## # early# # average# area#of#concern*# #Walked#alone## # early# # average# area#of#concern*#Toilet#trained# # early# # average# area#of#concern*#Fed#self# # early# # average# area#of#concern*#Dressed#self# # early# # average# area#of#concern*#Spoke#first#words# early# # average# area#of#concern*#Spoke#sentences# early# # average# area#of#concern*#Explain#any#areas#of#concern:# # # # # # # # # # ##&Health&History&and&Health&Concerns:&(circle#yes#or#no.#*#Please#explain#any#yes#answers#below)#ADD#(Attention#Deficit#Disorder)# # # # yes# no#Allergies# # # # # # # yes# no#Asthma/#Reactive#Airway#Disease# # # # yes# no#Autism#Spectrum#Disorder/Aspergers####### ### # yes# no#Behavior/Emotional#Concerns## # # # yes# no#Bleeding#disorders# # # # # # yes# no#Bone/Joint/Muscle#Concerns# # # # # yes# no#Bladder#or#Kidney#Concerns# # # # # yes# no#Bowel#Concerns#(constipation,#loose#stools)# # # yes# no#Chicken#Pox#Disease# #(note#month/year)# # # yes# no# date_____________#Concussion#(head#injuries)# # # # # yes# no# date_____________#Diabetes# # # # # # # yes# no#Digestive#Concerns#/#Special#Diet# # # # yes# no#Emotional#Concerns# # # # # # yes# no#Frequent#Ear#Infections#(?#Tubes)# # # # yes# no#Ear#or#Hearing#Concerns# # # # # yes# no###
Health&Questionnaire/Health&History&and&Concerns&(continued):&
Eye#or#Vision#Concerns# # # # # yes# no#Wears#glasses# # # # # # # yes# no##Feeding#Concerns#(aspiration,#gagging,#drooling)# # yes# no#Gastroesophageal#Reflux# # # # # yes# no#Genetic#Disorders# # # # # # yes# no#Growth#Concerns#(over/underweight,#short#stature)# # yes# no#Heart/#Congenital#Heart#Defect/Heart#Murmur# # yes# no#Headaches#or#Migraines# # # # # yes# no#Hormone#Deficiency#(thyroid,#growth,#adrenal,#other)## yes# no#Immune#Deficiency# # # # # # yes# no#Metabolic#Disorder# # # # # # yes# no#Neurological#Disorder### # # # # yes# no#Nosebleeds#frequently## # # # # yes# no#Respiratory#infections#frequently# # # # yes# no##Seizure#(febrile#or#otherwise)# # # # # yes# no#Sickle#Cell#Anemia# # # # # # yes# no#Sleep#Concerns## # # # # # yes# no#Strep#Throat#(scarlet#fever,#rheumatic#fever)# # # yes# no#Surgeries#/#Hospitalizations# # # # # yes# no# date____________#Tourettes#Syndrome# # # # # # yes# no#Other# # # # # # # # yes# no#If#yes,#explain:# # # # # # # # # # # # #
Add#additional#pages#if#necessary.#Current&Health&Status:&Does#your#child#have#any#allergies?# ####Yes# no###Are#these#allergies#life#threatening?# yes# no#If#yes,#describe______________________________________________________________________________________________##_______________________________________________________________________________________________________________##Is#your#child#currently#taking#medication?#(include#vitamins#and#meds#taken#as#needed,#such#as#Albuterol,#EpiPen)__________________________________________________________________________________________##Unless#the#following#has#already#been#discussed#with#district#administrators,#please#respond:#Has#your#child#ever#been#evaluated#for#Early#Intervention#Services?# yes# no#Has#your#child#ever#been#evaluated#for#a#learning#disability?# # yes# no# ## # # # # # # # # if#yes,#when__________#Has#your#child#ever#been#classified?# # # # # Yes# no# ## # # # # # # # # if#yes,#when__________#Has#your#child#ever#been#evaluated#for#speech#therapy?# # Yes# no# ## # # # # # # # # if#yes,#when__________##Family#Doctor/Practitioner#(name/address/phone):_____________________________________________________#Family#Dentist#(name/address/phone):___________________________________________________________________##I#give#permission#for#the#school#nurse#to#share#the#above#information#about#my#child#with#school#staff#who#works#directly#with#my#child.# # yes______###no________##Signature#of#Parent/#Guardian_________________________________________________________Date:_______________#
END'OF'HEALTH'SURVEY'# &
&SUMMIT&PUBLIC&SCHOOLS&
Medical Guidelines and Immunization
The Medical Evaluation form must be signed and completed by a New Jersey physician or advanced practice nurse with the provider's stamp on the back of the form. The physical MUST be within 365 days of enrollment. However, please bring a copy of your child's immunization record to registration. Regarding the Immunization Record: It is important that these records include the day, month, and year that your child received the following REQUIRED immunizations:
• 4 doses of Diptheria, Tetanus Pertussis Vaccine(DPT)* with one booster dose given on or after the fourth birthday
• 4 doses of Polio Vaccine (IPV)* with one booster dose given on or after the fourth birthday
• 3 doses of Hepatitis B vaccine* • 2 doses of Measles, Mumps, and Rubella Vaccine (MMR)* with first dose given after
first birthday, second dose given on or after fourth birthday • 1 dose of Varicella (Chickenpox Vaccine)* on or after first birthday
*Lab evidence of immunity is acceptable PRESCHOOL ONLY:
• 1 dose of Pneumococcal Vaccine on or after first birthday • 1 dose Influenza Vaccine (Flu) annually • 1 dose Haemophilus influenza B (Hib) on or after first birthday
GRADE 6 or older:
• 1 dose Tdap (Tetanus, Diptheria Acellular Pertussis) • 1 dose Meningococcal Vaccine
NOTE: For September enrollment, it is IMPORTANT that all forms be COMPLETE by June 1st. **IF YOUR CHILD HAS SPECIAL MEDICAL NEEDS (ALLERGIES, ASTHMA, ETC.) PLEASE CONTACT THE SCHOOL NURSE IN YOUR CHILD'S SCHOOL PRIOR TO ENROLLMENT.
#
#7#&SUMMIT&PUBLIC&SCHOOLS&Publicity&Consent&Form#
##We#are#sending#you#this#parental#consent#form#to#both#inform#you#and#to#request#permission#for#your#child’s#photo/image#and#personally#identifiable#information#to#be#published#in#print#media,#on#TV,#the#Summit#Public#School’s#website#@#www.summit.k12.nj.us#@#and#on#other#internet#media#websites#that#cover#news#or#publicity#about#our#schools.#(We#are#defining#publicity#as#information#that#is#disseminated#outside#of#our#schools.)####As#you#are#aware,#there#are#potential#dangers#associated#with#the#posting#of#personally#identifiable#information#on#a#website#since#global#access#to#the#internet#does#not#allow#us#to#control#who#may#access#such#information.#These#dangers#have#always#existed;#however,#we#as#schools#do#want#to#celebrate#your#child#and#his/her#work.#The#law#requires#that#we#ask#for#your#permission#to#use#information#about#your#child.##&#Pursuant#to#law,#we#will#not#release#any#personally#identifiable#information#without#prior#written#consent#from#you#as#parent#or#guardian.#Please#note#that#the#Summit#Public#Schools#does#not#ever#intend#to#disclose#for#publicity#purposes#students’#residential#or#email#addresses,#phone#numbers,#or#dates#and#times#of#class#trips,#but#does#foresee,#with#your#consent,#the#possibility#of#disclosing#for#publicity#reasons#student#names,#photos,#grade#levels,#and#schools.####If#you,#as#the#parent#or#guardian,#wish#to#change#your#child’s#publicity#permission#status,#you#may#do#so#at#any#time#in#writing#by#sending#a#letter#to#the#principal#of#your#child’s#school.####Please#check#one#of#the#following:####
o # I/We#GRANT#permission#for#this#student’s#photo/image,#name,#grade#level,#and##school#to#be#published#in#print#media,#on#TV,#the#Summit#Public#School’s#internet##website,#and#other#internet#media#websites#that#cover#news#or#publicity#about#the##Summit#Public#Schools.##
# #
o # I/We#DO#NOT#GRANT#permission#for#the#use#of#any#photo/image#or#other##information#about#this#student#to#be#used#for#any#publicity#purposes.##
##Please#Print##
Student’s#Name:##
#Student’s#School/Grade:#
#
#Relation#to#Student:#
#
##
Signature#of#Parent/Guardian#
#
#Date:#
#
#8&SUMMIT&PUBLIC&SCHOOLS&
Parent&Survey&#Dear#Parents#or#Guardians,## #In#Summit,#we#hope#to#develop#a#working#partnership#between#home#and#school#that#will#be#of#benefit#to#your#child.##To#do#that,#parents#and#teachers#share#their#observations,#concerns#and#expectations#in#many#ways.##One#effective#way#to#gather#information#is#through#the#use#of#a#questionnaire.###We#would#appreciate#it#if#you#would#take#a#few#moments#to#answer#the#questions#below#as#they#relate#to#your#child.##Please#return#this#with#your#registration#packet.##### # # # #Parent'/'Guardian'Name:# #
'Child’s'Name:#
##
# # ##
1. My#child’s#special#interests#(games,#books,#toys,#sports,#etc.)#are:#####
2. What#do#you#perceive#as#your#child’s#areas#of#strength?#####
3. What#do#you#perceive#as#your#child’s#area#of#need?##
###
4. Please#list#below#any#information#that#may#help#us#place#your#child#in#the#most#appropriate#class.#
####
5. On#the#back#of#this#sheet,#we#would#like#your#child#to#draw#a#picture#of#himself/herself.#
#####
PM#Kindergarten#Program!Drop!Off! 12:15!to!12:22!
! !Pick!Up! 3:15!
!
PM#Preschool#Program!Drop!Off! 12:20!to!12:30!
! !Pick!Up! 3:00!
!
#9!!
!
SUMMIT#PUBLIC#SCHOOLS!AM/PM#Session#Request#Form!
!In!the!area!below!please!indicate!your!preference!for!AM!or!PM!Session.!
!Criteria!considered!for!placement!include!the!composition!of!the!class,!instructional!needs,!gender,!diversity,!and!class!size.!
!Please#note#that#the#district#will#make#the#final#decision#regarding#placement#and#we#may#not#be#able#to#honor#all#requests.!
!AM#Kindergarten#Program!
Drop!Off! 8:15!to!8:30!! !
Pick!Up! 11:22!!AM#Preschool#Program!
Drop!Off! 8:50!to!9:00!! !
Pick!Up! 11:30!!
Student#Name# !!!Check#One:# o No#Request#–#My#child#can#be#in#AM#or#PM!
!
o Request#AM#Session!!
o Request#PM#Session#
Please#indicate#reason#for#request:!!!!!!!Home#Elementary#School:!
!❒ Brayton# ## Franklin# ## Jefferson# ## Lincoln#Hubbard## # Washington###
I#will#have#another#child#attending#the#Primary#Center#in#September:## Yes!!! No!
!
!Parent'Signature' Date!
#10&SUMMIT&PUBLIC&SCHOOLS&
School&Information&&&
&School&correspondence&is&sent&home&through&email.&&If&you&do¬&have&an&email&account,&a&hard©&will&be&sent&home&with&your&child.&''Child’s'Name:'___________________________________________________________________'&E]Mail(s):&&
_________________________________________________________________________________#
&
#
o I'don’t'have'access'to'E]Mail'
&&& & &Parent'Signature& & Date&
#
Title III ESL/Bilingual Department #11
Ana Ventoso • Supervisor of ESL/Bilingual • 908-273-1494 ext 5531 • [email protected]
Summit Public Schools
Date: ___________________ School:_________________ Counselor:_________________
HOME LANGUAGE SURVEY By identifying another language spoken at home, the following student will be screened for English as a Second Language placement. Students will take a placement test in order to determine the appropriate classes. Please answer the following questions: NAME OF STUDENT ____________________________________________________ STUDENT’S NATIVE LANGUAGE:________________________________________ PHONE NUMBER:___________________________ ALL LANGUAGES SPOKEN AT HOME_________________________________________ (CIRCLE PRIMARY LANGUAGE SPOKEN AT HOME) COUNTRY OF ORIGIN_______________________________________________________ DATE OF BIRTH OF STUDENT:________________ AGE:________________ MOST RECENT COMPLETED GRADE: __________ CURRENT GRADE:_____________ COUNTRY/CITY/STATE OF PREVIOUS SCHOOL:_________________________________
FOR INTERNAL USE ONLY SCREENING: UPON COMPLETION PLEASE LEAVE IN ESL TEACHERS MAILBOX
! BACKGROUND HISTORY – NO ESL NEEDED
! NEEDS ASSESSMENT –
W – APT RESULTS ____________________________
! POE – NO ENGLISH LANGUAGE SKILLS – W-APT RESULTS ___________________ FIRST DAY OF SCHOOL IN SUMMIT: _________________________________________
