HASBROUCK HEIGHTS PUBLIC SCHOOLS

REGISTRATION FORM

Student’s Name:                                                                                              

                                          SECTION A:  If the student is living with a parent or guardian whose
permanent home is the address listed on page 1 of this application and is located in the district.

                                         SECTION B:  If the student is living with a person domiciled in the district, other than the parent or guardian. (“Affidavit Student”)

                                         SECTION C:  If the student is living with a parent or guardian temporarily residing within the district.

                                         SECTION D:  If the student’s situation is not addressed by Section A,B or C or if any of the circumstances in Section D apply (Special Circumstances)

Please check the appropriate section A,B,C or D, according to the situation best matching the student’s circumstance.

If you have any questions regarding the completion of the attached forms kindly contact the appropriate secretary listed below:

Euclid School - Pat Carlin                                    201-393-8176
                         Lincoln School -  June Raymond                          201-393-8182
                         Middle School - Fran DelVecchio                        201-393-8190
                         High School - Pat Kunzmann                                201-393-8164

REGISTRATION FORM

Date:_________________ School:_____________________________________

Student:                                                                                                                                               
                        Last Name                               First Name                   Middle Name

Age:                                Date of Birth:____________________        Male:____
                                                                                                           Female:____
City of Birth:                                           State of Birth:                                                                        

Country of Birth (if other than the USA):                                                                                  

Race (please check):                 Hispanic                       American Indian          
                                                     Asian                                         Black        
                                    Pacific Islander                                           White        

Name of Parent(s)/Guardian(s):                                                                                                            

Person Enrolling Student:_________________________________________________________

Relationship to Student If Other Than Parent:_________________________________________

Child Lives With (circle one):     Both parents    Mother             Father              Guardian

Student’s Physical Address:______________________________________________________________________

Mailing Address (if different):_____________________________________________________

Home Telephone (Including Area Code):_____________________________________________

Other Phone or Fax (if any):_______________________________________________________

Parent(s)/Guardian(s) Physical Address:______________________________________________________________________

Mailing Address (if different):  ____________________________________________________

_____________________________________________________________________________

Are you and your child currently homeless?                                                                                          

Home Telephone (including area code):______________________________________________
 
Other Phone or Fax (if any):_______________________________________________________

Native Language of Parent/Guardian/Person Enrolling Student: __________________________

Is English Spoken and Understood By Parent/Guardian/Person Enrolling Student? Yes_________ 
No  __________        

Native Language of Student:  ______________________________________

Is English Spoken and Understood By Student? Yes _____ No  _____

Is your child currently covered by Health Insurance?  Yes                        No                

If yes, who is his/her health care provider?                                                                                

Date of your child’s last medical examination (attach proof):                                          

Date of your child’s last dental examination (attach proof): ________________________

Date of your child’s last lead test:                                                                                             

            Lead Level:                                         

Date of your child’s polio immunization:                                                                                    

Proof of Residency: (Copy of one document required)

1. Property Tax Bill _____                               4.  Lease  _____
2. Deed _____                                                5.  Mortgage  _____
3. Contract of Sale  _____                               6.  Signed Letter From Landlord

How long have you lived in this residence?  ___________

Please list four forms of proof as evidence of personal attachment to the address given as your residence such as Voter registrations, licenses, permits, financial account information, utility bills, delivery receipts, and other evidence of personal attachment to the address given:
1.  ________________
2.  ________________
3.  ________________
4.  ________________

Also, please provide a photo identification:
                         Driver’s License  __________ Employee __________
                         County Residency  _________ Passport  ___________
                                                                                    Other  _____________
Student Information:          Birth Certificate  _____
Transfer Card  _____
Immunization Record  _____
Most Recent Report Card  _____
Name & Address of Previous School :  ____________________
____________________________________________________

REGISTRATION FORM (cont’d)

Educational Services — Previous School
Classified Student  ______
504 Student  _____
Speech/Language  _____
Basic Skills Instruction ______
ESL Program  _____
PAC Program  _____
Other Program Offerings  _____

Explain:  ______________________________________________________________________________

______________________________________________________________________________

If High School student, list athletic teams in which you have participated:
            1.  ______________________________
            2.  ______________________________
            3.  ______________________________
            4.  ______________________________

Signature of person enrolling student: _______________________________________________

(For Administrative Use Only)

School Placement & Grade
Euclid School Grade  ___________________________
Lincoln School Grade  __________________________
Middle School Grade  ___________________________
High School Grade______________________________
Out of District Placement  ________________________
Pre-School  _____________________________________
Special Services (Explain):  _________________________________________________
________________________________________________________________________

Application Processed by:                                                                 Date;  _____________

Principal’s Signature:                                                                          Date:                              

Superintendent of Schools: _______________________________Date:  ________________

updated 8.13.08