Southington Public Schools

Southington Public Schools Student Registration Form

|School Student will be attending: | |Enrollment Date: | |

|Entry Grade Level: | |Graduation Year: | |

|Student ID#: | |CT SASID#: | |

Note: Student # will be assigned by computer unless student is returning to SPS. Obtain student #s from the SPS last attended.

Previous School Information

|School Last Attended: | |City/State: | |

|Grade Level from Previous School: | |

Has student ever been enrolled in the Southington School District before? YES NO

|If yes, which school: | |Date Left: | |

| |If yes, name of facility: | |

|Has the student attended Preschool? YES NO | | |

|Student’s Legal Last Name: | |First: | |Middle:* | |

*Middle Name Required. Check here if student does not have a middle name Has middle initial only

|Birth Date: | |Birthplace (City & State): | |

|Home Phone: | - - |Unlisted? YES NO |

|Home Address: | |

|City: | |State: | |Zip: | |

|Mailing Address | |

|City: | |State: | |Zip: | |

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• Language that the student learned first

• Primary language spoken by students’ parents, guardians, or other

people with whom the student lives

• Primary Language spoken by the student at home

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Ethnicity – Please respond to questions 1 and 2: (Official Federal Codes)

|1. |Is the student Hispanic/Latino? YES NO |

|2. |Is the student from one or more races using the following (choose ALL that apply): |

| American Indian/Alaskan | Asian | Black or African American | Native Hawaiian or Other Pacific | White |

| | | |Islander | |

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Gender: Male Female

|Mother’s Maiden Name: | |

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|Check Citizenship Status: |US Citizen |Dual National |Non-Resident |Alien Resident |Alien Other |

|If not an American Citizen, when did student enter the US? | |Grade at first US School? | |

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Parent Guardian Information

|Student lives with | |Relationship to student | |

Mailing label header

Please Check One of the Following:

Two Parents in home Sole Custody Joint Custody Separated

Custody Transfer Foster Placement Emancipated Single Parent

Restrictions of Contact and Information (when applicable) Paperwork must be provided.

Order of protection Custody papers specify restriction Other documentation provided

Papers Provided Papers Provided Specify_______________________

|Name of Person Restricted: | |Expiration Date: | |

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|Mother’s Last Name: | |First Name: | |

|Address (if different from student): | |

|City: | |State: | |Zip: | |

|Hm Ph * | - - |Alt Ph * | - - |Wk Ph * | - - |

|*Indicate with a check mark the number we should use for the district School Messenger. The number checked will be used when the school/district has a |

|message to deliver to all parents/guardians. |

|Email: | |Employer: | |

Check all that apply: Receives Mailings Has Custody Living With

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|Father’s Last Name: | |First Name: | |

|Address (if different from student): | |

|City: | |State: | |Zip: | |

|Hm Ph * | - - |Alt Ph * | - - |Wk Ph * | - - |

|*Indicate with a check mark the number we should use for the district School Messenger. The number checked will be used when the school/district has a|

|message to deliver to all parents/guardians. |

|Email | |Employer | |

Check all that apply: Receives Mailings Has Custody Living With

************************************************************************************************************

|Guardian Name | |Relationship to student | |

|Address (if different from student): | |

|City: | |State: |Zip: |

|Hm Ph * | - - |Alt Ph * | - - |Wk Ph * |-- |

|*Indicate with a check mark the number we should use for the district School Messenger. The number checked will be used when the school/district has a|

|message to deliver to all parents/guardians. |

|Email | |Employer | |

Check all that apply: Receives Mailings Has Custody Living With

************************************************************************************************************

|Other Contact Name | |Relationship to student | |

|Address (if different from student): | |

|City: | |State: |Zip: |

|Hm Ph * | - - |Alt Ph * | - - |Wk Ph * | - - |

|*Indicate with a check mark the number we should use for the district School Messenger. The number checked will be used when the school/district has a|

|message to deliver to all parents/guardians. |

|Email | |Employer | |

Check all that apply: Receives Mailings Has Custody Living With ************************************************************************************************************

I give permission for my child to be photographed and/or videotaped at school for educational purposes, the school website or local media agencies. YES NO

I have read and agree with SPS Acceptable Use Policy. YES NO

STUDENT INSURANCE COVERAGE

CT Public Act 07-04 requires families in public school districts to annually report whether the pupil has health insurance. This act also requires that we provide parents and guardians with information regarding state-sponsored health insurance programs. Please respond accordingly:

My child is covered by insurance. YES NO

Will you insure your child with the school insurance program? YES NO

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Has your child participated in any of the following programs in any school? If yes, please indicate most recent year in program and what school.

|SPECIAL EDUCATION/IEP | YES NO |If yes, what year | |School | |

(Individual Education Program)

|504 PLAN | YES NO |If yes, what year | |School | |

|ESL/ELL | YES NO |If yes, what year | |School | |

|GIFTED/TALENTED | YES NO |If yes, what year | |School | |

|SPEECH/LANGUAGE | YES NO |If yes, what year | |School | |

|TITLE I (CHAPTER I) | YES NO |If yes, what year | |School | |

|OTHER (Specify) | YES NO |If yes, what year | |School | |

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EMERGENCY CONTACT(S)

IN CASE OF EMERGENCY, PARENTS/GUARDIANS WILL ALWAYS BE CONTACTED FIRST. PLEASE LIST ADDITIONAL PEOPLE THAT ARE AUTHORIZED TO PICK UP YOUR CHILD IN CASE YOU CANNOT BE REACHED (You may list up to 2 phone numbers for each contact)

|Contact Name |Relation |Phone (must include area codes) |Extension |

|1 | | |( ) - | |

| | | | | |

| | | |( ) - | |

|2 | | |( ) - | |

| | | | | |

| | | |( ) - | |

|3 | | |( ) - | |

| | | | | |

| | | |( ) - | |

|DR | |DOCTOR |( ) - | |

| | | | | |

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Sibling(s)

|Name | |Date of Birth | |School Attending | |

|Name | |Date of Birth | |School Attending | |

|Name | |Date of Birth | |School Attending | |

**************************************************************************************************

PLEASE READ AND SIGN BELOW

The information on this form is accurate. I will notify the Southington Public Schools with information changes and updates

Parent/Guardian Signature Date

Southington Public Schools

Southington, Connecticut

EMERGENCY MEDICAL AUTHORIZATION

|Student’s Name | |Sex | |School | |Grade | |

|Home Address | |Date of Birth | |

|Mother’s Information (Full Name) | |

|Home Ph | - - |Work Ph | - - |Cell/Emergency Ph | - - |

|Father’s Information (Full Name) | |

|Home Ph | - - |Work Ph | - - |Cell/Emergency Ph | - - |

In case of illness or accident during school hours when no one can be reached at home, please indicate below a person who may be contacted and/or transport your child.

|1. |Emergency Contact Person | | | - - |

Relative/Neighbor Telephone

|2. |Emergency Contact Person | | | - - |

Relative/Neighbor Telephone

HEALTH INFORMATION

|Known Medical Problems | |

|Medications | |

|Known Allergies | |

|Medications | | | |

|Physician | |Telephone | - - |

|Hospital Choice | |Insurance Company & Policy # | |

• In an emergency, your child will be transported to the nearest medical facility to obtain appropriate treatment as deemed necessary by the local ambulance service.

• I give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.

• I, the undersigned, do hereby authorize employees of the Southington Board of Education to contact directly the persons named on this form and do authorize the named physician to render such treatment as may be deemed necessary in an emergency for the health of said child.

• In the event that the physician, other persons named on this card, or parents cannot be contacted, the school employees are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the aforesaid child.

• The school district will not be held financially responsible for emergency care/or transportation for said child.

Signature of Parent/ Legal Guardian Date

Southington School Health Services

Southington, Connecticut

To: Parents or Legal Guardians

From: Marie Bordonaro RN, BSN, NCSN

School Nursing Supervisor

Subject: Health Examination Requirements

Date: January 2011

The State of Connecticut requires each pupil to have a complete health examination before entering public school. Listed below are the immunization and health assessment requirements for all students:

No student may start school without proof of the following prior to the first day of school:

Blue Physical Form

• This form must be filled out completely – parent/guardian fills out the front page and the physician completes the remaining portions of the form. Doctor must include hemoglobin/hematocrit, vision, hearing, and all areas as mandated under Connecticut State law.

• Copies of the form are available on our website at . They can be found by clicking on the Departments tab, then Health Services, and then Health Forms.

DTaP /Td/Tdap

• At least four doses with the last dose must be given on or after the fourth birthday. Students who start the series at age 7 or older only need a total of three doses.

Polio

• At least three doses and the last dose must be given on or after the fourth birthday.

MMR

• One dose on or after the first birthday.

Measles

• The second dose of measles vaccine (or MMR) must be given at least four weeks after the first dose.

Hib

• Children less than five years of age need one dose at twelve months or older. Children five and older do not need proof of Hib vaccination.

Hepatitis B

• Three doses.

Varicella

• One dose on or after the first birthday or verification of disease.

• VARICELLA VACCINE: For students younger than 13 years of age, one dose given on or after the first birthday. For students 13 years of age or older, two doses given at least four weeks apart.

• VERIFICATION OF DISEASE: Confirmation in writing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.

Tuberculin Risk Assessment

• A tuberculin risk assessment is highly recommended.

Chronic Disease Assessment

• A chronic disease assessment is required.

Immunization requirements are subject to change in accordance to State laws. Consult your child’s physician at time of visit.

PROPOSED new immunization requirements for the 2011-2012 school year include the following:

• One dose of pneumococcal conjugate for students less than five years old entering kindergarten.

• Second dose of varicella, mumps and rubella vaccines for students entering kindergarten.

• One dose of Tdap for entry into grade seven.

• Second dose of varicella, mumps and rubella for entry into grade seven.

Southington School Health Services

Southington, Connecticut

In addition, please make note of the following:

• During grade 6 to be completed by entry into grade 7, Southington Board of Education policy requires each pupil to have a health examination. The physical exam must be done within one year and before the first day of the next school year. No student may enter grade seven without this physical.

• During grade 9 to be completed by entry into grade 10, in compliance with State of Connecticut legislation, the Southington Board of Education requires each pupil to have a health examination. The physical exam must be done within one year and before the first day of the next school year. No student may enter grade ten without this physical.

• Postural Screening – Students who have been examined by their physician will be excused from the school postural screening for that year unless parental request has been made to the school nurse.

• New Students from Out of State – A physical exam done within one year will be accepted (must meet all requirements of Connecticut State Law and local health policies). A tuberculin risk assessment and chronic disease assessment are also required. If no proof is presented, the student will be excluded from school.

• New Students from Out of the Country – A physical exam must be done prior to enrolling (must meet all requirements of Connecticut State Law and local health policies). A tuberculin skin test and chronic disease assessment are required. If the requirements are not met, the student will be excluded from school.

• Annual Sports Physicals - Students Grades 6 to 12 – According to Southington Board of Education policy, every student trying out and participating on a school sport team must submit a completed physical examination form and Medical Emergency Form/Sports Participation Permission form to the school nurse each year. The “blue form” or the State of CT Department of Education Health Assessment Record is now the Southington Sports Physical form as well. The sports physical is valid for thirteen months.

❖ The front side of the blue physical examination form must be filled out and signed by a parent/legal guardian.

❖ The doctor must complete and sign the back side of physical examination form. These forms are available in the health offices and online at:

You may wish to plan ahead to schedule your child’s physical to coincide with any necessary sports physical for that school year.

If you are financially unable to meet these requirements and your child is receiving free or reduced hot lunch, please contact your school nurse and arrangements will be made with the school physician to conduct your child’s mandated physical. The State of Connecticut HUSKY Plan offers a comprehensive health care benefit package for Connecticut children up to age 19. Depending on your family’s income, there may be no cost to you. Call your school nurse or 1-877-CT-HUSKY for more information.

The attached Health Assessment Record (blue form) should be on file by June 1, 2011, but no later than the first day of school when your child enters kindergarten, grade seven or grade ten. This letter serves as ample notification of mandatory physicals to parents whose children are entering kindergarten and currently in grades six and nine. Parents and students are advised that they can make an appointment with principals or school nurses to discuss issues they may have about the health examinations. If after this discussion the health assessment is not complete, your child will not be allowed to be enrolled until all requirements are met. This requirement includes all children new to Connecticut schools. Thank you for your cooperation.

Parents are urged to schedule a doctor’s appointment well in advance of the June 1, 2011 deadline. It is advised to keep a copy of your child’s physical form for your records.

Please contact your school nurse with any questions.

Southington Board of Education

Registration Office

49 Beecher Street

Southington, Connecticut 06489

Phone (860) 628-3204 Fax (860) 628-3205

Dear Parent/Guardian,

All new students are required to register at the Southington Board of Education Registration Office before they are admitted into the appropriate school. Parents/Guardians must verify residence in the Town of Southington, in person, at the Registration Office. The exception is parents/guardians of incoming kindergarteners. Kindergarten parents will be registering and submitting proof of residency at the districted school their child will be attending.

Currently enrolled students, who moved within town and need to change their address, must change their address at the Registration Office ~ even if the school district is not affected.

In order to complete the registration and residency verification you will need the following:

1. A full size birth certificate (not a wallet size) for all students born in the United States. Students born outside of the United States need to present a passport/visa or green card. Please note we do not accept foreign birth certificates.

2. Court issued guardianship documentation issued by the State of Connecticut if the parent of the child is not the legal guardian.

3. a. Homeowners must present one of the following: a current mortgage statement/bill, a copy of the Southington home property tax statement, or the title page of the current homeowner’s insurance policy.

b. Renters must present a current rental or lease agreement.

4. In addition, you must bring at least one current utility bill (electricity, gas, or phone).

5. If the student and the parent/guardian are living in a dwelling that is rented or owned and occupied by another person, the person who owns or rents the dwelling must bring the documentation mentioned in numbers 3 and 4, present photo identification, and sign a Certificate of Residency form (copy attached).

*Verification of residency must be completed before the student will be admitted to any Southington Public School.

Southington Board of Education

Registration Office

49 Beecher Street

Southington, Connecticut 06489

Phone (860) 628-3204 Fax (860) 628-3205

CERTIFICATE OF RESIDENCY

If the student and the parent/guardian are living in a dwelling that is rented or owned and occupied by another person, the person who owns or rents the dwelling must bring the required documentation, present photo identification, and complete/sign this Certificate of Residency form.

School: School Year:

As part of our residency verification process, we are requesting that you as the owner/tenant of the residence in Southington verify that:

Name of Student(s):

and Student(s) Parent/Guardian: reside with

me at .

Address, Apt/Unit #, Town

I, certify that the above named student(s) and

Local Resident/Relative, etc.

parent(s)/guardian(s) reside with me at the above listed address, in a residence owned or occupied by me in the Town of Southington. I realize that if I make a false statement as to residency, I may be held liable for a share of the cost for the education of the said student(s) if they, in fact, do not reside in Southington.

I agree to notify the school immediately regarding the termination of the student’s full time physical presence (permanent residency), in the town of Southington in which event the student will no longer be eligible for free school privileges. Finally, I understand that should the student be found to be attending Southington schools illegally, the town of Southington reserves the right to recover the costs of such education from me, the undersigned.

I understand that a perjured or fraudulent statement may lead to the disenrollment of the above-named student(s) and may lead to my prosecution under the criminal statutes of the State of Connecticut which is stated below. (Larceny 53a122) I also understand that this document may be used as evidence in a court of law.

Larceny lst Degree 53a122 – The property or service is obtained by defrauding a public community and such property exceeds $2,000.

Class B. Felony – not less than one year or more than 20 years and/or a fine up to $10,000.

Signed: Date:

Legal Resident of Southington, CT

Signed: Date:

Parent/Guardian of Student(s)

*If you have any questions, please contact the Assistant Superintendent’s Office at Southington Public Schools at 860-628-3204.

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Southington Public Schools

Southington, Connecticut

Registration Packet

2011-2012

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SOUTHINGTON PUBLIC SCHOOLS

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2011-2012 School Year

Dear Parent and/or Guardian:

Welcome to Southington Schools!!

We look at the opportunity to work with you and your child as an honor and a privilege. It is my belief that you are entering a school district that takes great pride in their future leaders. There simply is no more important partnership than the work that our staff will do with you regarding the education of your son or daughter. I am quite certain that you will find employees of our schools to be user-friendly, committed to excellence, and dedicated to making a difference in the life of every child.

The following materials are included in this packet and required prior to being permitted to enter Southington Public Schools:

• Birth Certificate – Full Size

• Student Registration Forms

• Proof of Residency

• Physical Examination Records (form included)

• Emergency Medical Authorization

Parents must present proof of their child’s vaccination against Measles, Mumps, Rubella, Poliomyelitis, Hepatitis B, Diphtheria, Pertussis, Tetanus (DPT) and Varicella. Exemptions will only be granted for medical or religious reasons. Medical exemptions require written documentation by a physician. Immunization requirements are subject to change in accordance with state laws. Consult your child’s physician at time of visit.

According to Connecticut law, the above information must be completed or your child will be unable to attend school. In addition, a dental checkup is strongly urged, although not an actual requirement.

Attention to the physical health of your child will assist him or her greatly in having an enjoyable and valuable educational experience. We know we can count on your complete cooperation. If you have any questions, please feel free to contact the elementary school your child will be attending.

In closing, I look forward to this journey with you and wish you and your child only the best as a new member of our school system. Together, we will make a difference…one student at a time.

Respectfully,

Dr. Joseph V. Erardi, Jr.

Superintendent of Schools

Joseph V. Erardi, Jr., Ed.D.

Superintendent of Schools

Howard J. Thiery

Assistant Superintendent for instruction & learning

Board of Education

Brian S. Goralski

Board Chairperson

Terri Carmody

Vice Chairperson

Jill Notar-Francesco

Secretary

Colleen W. Clark

David J. Derynoski

Rosemarie Micacci Fischer

Patricia P. Johnson

Patricia Queen

Kathleen C. Rickard

49 Beecher Street

Southington, CT

06489

Office Telephone

(860) 628.3202

Fax

(860) 628-3205

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Language Survey

Office Use Only:

Primary Language code___________

Ethnicity

Page 2

Student Registration

Mother Information

Father Information

Guardian Information

Other Contact Information

Page 3

Student Registration

C:\Forms\Emergency Medical Authorization.doc 04/2009

Page 2

Health Requirements

2011-2012 School Year

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