PARSIPPANY-TROY HILLS TOWNSHIP SCHOOLS



5943600000PARSIPPANY-TROY HILLS TOWNSHIP SCHOOLSREGISTRATION FORM 2019-2020 FORMCHECKBOX New Student TODAY’S DATE: FORMTEXT ????? FORMCHECKBOX Returning to the District FORMCHECKBOX Information ChangeSTUDENT NUMBER:All information will be kept confidential. It will be appreciated if you answer all questions to the best of your knowledge. However, if you do not wish to respond to specific questions, you may request to speak to the principal. PLEASE CHECK OR FILL IN THE CORRECT INFORMATION. PLEASE PRINT OR TYPE ALL INFORMATION. Thank you for your cooperation.1.School: FORMTEXT ?????Counselor: (School Use Only) 2.Student Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (First) (Middle) (Last) (Suffix Jr. III, etc)3.Student’s Nick Name: FORMTEXT ????? 4.Birth Date: FORMTEXT ????? (Month/Day/Year) 5. Ethnicity: Hispanic FORMCHECKBOX YES FORMCHECKBOX NO Race: White FORMCHECKBOX Black/African American FORMCHECKBOX Asian FORMCHECKBOX (CHECK ALL THAT APPLY) American Indian/Alaskan Native FORMCHECKBOX Native Hawaiian/Pacific Islander FORMCHECKBOX 6.Enrollment/Entry Date: FORMTEXT ????? 7. Grade: FORMTEXT ?????8. Gender: M FORMCHECKBOX F FORMCHECKBOX 9. Year of Graduation: FORMTEXT ?????10. Birth City: FORMTEXT ????? Birth State: FORMTEXT ?????Birth Country: FORMTEXT ?????11.What is the primary language of the family: FORMTEXT ????? 12.Language spoken at home: FORMTEXT ?????13.Date entered USA: FORMTEXT ?????14.Date First Entered a US School (Including Preschool): FORMTEXT ?????15.Transfer from: FORMTEXT ????? (School)(City) (State or Country) FORMTEXT ????? (Address)16.Student’s Home Address: FORMTEXT ????? (Street) (PO Box) FORMTEXT ????? (City) (State) (Zip)17.Home Phone:( FORMTEXT ?????) FORMTEXT ?????Unlisted:Yes FORMCHECKBOX No FORMCHECKBOX 18. Parent/Guardian’s marital status: Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Separated FORMCHECKBOX Widow FORMCHECKBOX Widower FORMCHECKBOX Civil Union FORMCHECKBOX Comment: FORMTEXT ?????19.Parent/Guardian Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (PRIMARY) (First) (Middle)(Last)20.Relationship to child: Mother FORMCHECKBOX Father FORMCHECKBOX Other: FORMTEXT ????? 21.Mailing Address: FORMTEXT ????? (if different from student’s in Line 16 above) 22.Cell Phone:( FORMTEXT ?????) FORMTEXT ?????Email:Needed for Genesis Parent Portal FORMTEXT ?????23.Work phone:( FORMTEXT ?????) FORMTEXT ?????24.Spouse Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (First) (Middle) (Last)25.Relationship to child: Mother FORMCHECKBOX Father FORMCHECKBOX Other: FORMTEXT ????? 26.Mailing Address: FORMTEXT ????? (if different from student’s in Line 16 above) 27.Cell phone:( FORMTEXT ?????) FORMTEXT ????? Email:Needed for Genesis Parent Portal FORMTEXT ?????28.Work phone:( FORMTEXT ?????) FORMTEXT ?????29.Emergency Contact - Name: Mr./Mrs./Ms. FORMTEXT ?????30.Relationship: FORMTEXT ?????31.( FORMTEXT ?????) FORMTEXT ????? (Area Code) (Ext.) (Must be different number from student’s home telephone number)32. Second Parent Mailing: Yes FORMCHECKBOX No FORMCHECKBOX IF YES, complete numbers 33 – 38 33.Parent/Guardian Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (SECONDARY)(First) (Last) (Middle)34.Relationship to child: Mother FORMCHECKBOX Father FORMCHECKBOX Other: FORMTEXT ????? 35.Home Address: FORMTEXT ????? FORMTEXT ?????(Street) (PO Box) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (City) (State) (Zip)36.Home phone:( FORMTEXT ?????) FORMTEXT ?????Email:Needed for Genesis Parent Portal FORMTEXT ?????37.Cell Phone:( FORMTEXT ?????) FORMTEXT ?????38.Work phone number:( FORMTEXT ?????) FORMTEXT ?????If the student’s parents are domiciled in different districts, regardless of which parent has custody, please complete the 39. 39. 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.) FORMTEXT ????? FORMTEXT ?????Does the student reside with one parent for the entire year? If so, with which parent and at what address? FORMTEXT ????? FORMTEXT ?????If not, for what portion of time does the student reside with each parent and at what addresses? FORMTEXT ????? FORMTEXT ?????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? FORMTEXT ?????40.Privacy (Military) Yes FORMCHECKBOX No FORMCHECKBOX 41.Media Release Yes FORMCHECKBOX No FORMCHECKBOX 42. Please check programs in which student has participated: FORMCHECKBOX Supplemental Instruction FORMCHECKBOX Gifted & Talented FORMCHECKBOX Special Education FORMCHECKBOX ESL/LEP FORMCHECKBOX 504 FORMCHECKBOX Child Study Team Evaluation FORMCHECKBOX (IEP) Individualized Education Program43. SIBLING INFORMATION NAMEBIRTH DATESCHOOLGRADE1) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????44.Physician’s Name: Dr.(Elementary Use Only) FORMTEXT ????? 45.( FORMTEXT ?????) FORMTEXT ?????46. FORMTEXT ?????47. Print Parent/Guardian’s Name Signature Parent/Guardian48. FORMTEXT ?????49. Date Signature of School Official Registering the Studentjfb/Registration/Documentation of Residency Form/Revised Jan 2019PARSIPPANY-TROY HILLS TOWNSHIP SCHOOLSAnytime any information on this form changes, it is necessary to tell the school in order to update our files. Since this system utilizes one central file, it is essential that this information be accurate at all times.DIRECTIONS FOR COMPLETING STUDENT REGISTRATION FORM 1.Print the name of the school. 2.Print the student’s first name, middle name, and last name. 3.Print Student’s Nick Name. 4.Enter student’s birth date in month/day/year. 5.Check all that apply regarding ethnicity and race. 6.Disregard enrollment/entry date. 7.Enter present grade. 8.Check whether student is male or female. 9.Disregard year of graduation.10.Print city of birth, print state of birth, and print country of birth.11.Print primary language, including dialect, of family.12.Print language spoken at home.13.Print date entered USA, if applicable.14.Print date first entered a US School (including Preschool), if applicable.15.Print name of previous school child attended. Print city, state or country of that school. If none put N/A.16.Print number and street, apartment number, city, state, and zip code of student’s home address.17.Print home phone number.18.Check marital status of parent/guardian. If any custodial restrictions, please indicate under comment.19.Print first name, middle name, and last name of parent/guardian. (PRIMARY)20. Indicate relationship of parent/guardian to this student.21. Print the mailing address. (If different from Line 16 above)22. Print cell phone number of parent/guardian and email address of parent/guardian if you have one.23. Print Work phone number.24.Print first name, middle name, and last name of spouse.25.Indicate relationship of spouse to this student.26.Print spouse’s address (If different from Line 16 above) 27.Print spouse’s cell phone number and email address of spouse if you have one.28.Print Work phone number.29.Print name of emergency contact person.30.Print relationship of emergency contact person to student.31.Enter emergency contact person’s telephone number. THIS MUST BE A DIFFERENT NUMBER FROM STUDENT’S HOME TELEPHONE.32. Check yes or no for Second Parent Mailing. (SECONDARY) If a second parent mailing (This means to a different address) for correspondence from the school is required complete numbers 33-38 with pertinent information.33.Print first name, middle name, and last name of parent/guardian. (SECONDARY)34.Indicate relationship of parent/guardian to this student.35.Print number and street, apartment number, city, state, and zip code of home address.36.Print home phone number and email address of parent/guardian if you have one.37. Print cell phone number of parent/guardian if you have one.38 Print Work phone number.plete if student’s parents are domiciled in different districts.40.Check yes or no for student information to be restricted. Checking yes does not remove the information from the computer, but rather indicates your wish to have the information restricted from being sent to outside agencies.41.Check yes or no for receipt of Media Release Form.42.If student has participated in any of the programs listed, please check.43.Sibling Information must be completed. Print name(s), birth date(s), school, and grade of other child(ren) in the family.44.Print name of student’s physician.45.Enter physician’s telephone number.46.Print parent/guardian’s name.47.Write signature.48.Print date.49.Disregard.PARSIPPANY-TROY HILLS TOWNSHIP SCHOOLS DOCUMENTATION OF RESIDENCYSCHOOL USE ONLYDocumentation of ResidencyAll parents/guardians must provide current documents as proof of residency in the Township of Parsippany-Troy Hills. Documents are required to clearly indicate the names and addresses provided for the registration of all students. Individuals must provide one (1) document from Category A and two (2) documents from Category B.Category A – One (1) documentCategory B – Two (2) documentsContract of saleMortgage document or payment bookProperty tax billRecorded deedSigned lease Bank Statement (block out figures)Gas BillCable BillInsurance BillCredit Card StatementPaycheck StubDriver’s LicenseTelephone billElectric BillVehicle RegistrationFinancial account informationVoter registrationWater/Sewer Billor any other evidence of personal attachment to your residence of domicile.For Guardians OnlyGuardians must provide proof of legal guardianship by providing a copy of Court orders, State agency agreements, or other evidence of court or agency placements or directives. ORAffidavits, certifications and sworn attestations pertaining to statutory criteria for school attendance, from the parent, legal guardian, person keeping an "affidavit student," person(s) with whom a family is living, or others as appropriate. ______________________________________ _______________________ Verified by Building Principal (Signature) (Date)1143005143500FOR SCHOOL USE ONLY 3. FORMCHECKBOX Needs to make an appointment with Office of the Superintendent for Verification of Residency. Form received from Superintendent on ____________________________.jfb/Registration/Reg Form/Revised Jan 2019 ................
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