K-12 Student Registration Packet - Hoboken Public …[email protected] Where Students Come First PLEASE COMPLETE ALL REGISTRATION FORMS. Requirements for Registration: Child

Hoboken Public School District

K-12 Student Registration Packet 2020-2021 School Year

HOBOKEN BOARD OF EDUCATION STUDENT DATA / ENROLLMENT CLERK

524 Park Avenue v Hoboken, NJ 07030 v 201.356.3619 v Fax:201.792.5175

Brunilda Munoz Student Data/Enrollment Clerk [email protected]

Where Students Come First

PLEASE COMPLETE ALL REGISTRATION FORMS.

Requirements for Registration:

Child must be 5 years of age on or before October 1, 2020 (Kindergarten) Immunization Record (original) Birth Certificate or Passport (original) Transfer from previous school (if applicable) Last Report Card (if applicable) High School Students must have Transcript for all subjects Parent's Photo ID

Two (2) current proofs of residency are required. You must have one Primary proof and one Secondary proof. (Please do not bring two secondary proofs, documentation will not be accepted. All original documents must have either or both p ar en t/gu ar d ian ’s name . Acceptable proofs include documentation such as:

Primary Proof (must have one) Secondary

Please bring original documents in order to speed registration process. All requirements must be met for registration. Please note if all requirements are not met the registration process will be delayed.

In order to save time, parents may download the all required registration forms in advance, from the Hoboken Board of Education website at www.hoboken.k12.nj.us

Deed PSE & G Bill

Mortgage Statement Cable TV/ Internet/ Phone

Lease Bank Statement

Health Insurance Statement

Water or Tax Bill

Pk-3⎕ Pk-4⎕ ELEMENTARY⎕ MIDDLESCHOOL⎕ HIGHSCHOOL⎕ STUDENTID# SID#

HOBOKENPUBLICSCHOOLSTUDENTENROLLMENTFORM

PLEASEPRINTALLINFORMATIONEVERATTENDEDSCHOOLINHOBOKEN:YES⎕NO⎕IFYES,PROVIDESCHOOLYEAR SCHOOL

STUDENTINFORMATION:LASTNAME FIRSTNAME MIDDLEINTIAL

GRADE GENDERMALE⎕ FEMALE⎕

DATEOFBIRTH

ETHNICITYHISPANICORGIN⎕NON-HISPANICORGIN⎕

RACE(MUSTCHOOSEONE)WHITE-EUROPE/NORTHAFRICA/MIDDLEEAST⎕ BLACK/AFRICANAMERICAN⎕NATIVEHAWAIIAN/PACIFICISLANDER⎕AMERICANINDIAN/ALASKANNATIVE⎕ASIAN/CHINA/INDIA/JAPAN/KOREA/PHILIPPINES⎕

ADDRESS APT# HOMETELEPHONENUMBER

CITY STATE ZIPCODE

NAMEOFSTUDENTHEALTHINSURANCE BIRTH CITY/ BIRTH STATE/ BIRTHCOUNTRY U.S.ENTRYDATE(IFAPPLICABLE)

SCHOOLLASTATTENDED(NAMEOFSCHOOL,CITY&STATE)

1. PARENT/GUARDIANINFORMATIONLASTNAME FIRSTNAME RELATIONSHIP

HOMETELEPHONENUMBER MOBILENUMBER EMAILADDRESS

EMPLOYERINFORMATION EMPLOYERWORKNUMBER EXT

2. PARENT/GUARDIANINFORMATIONLASTNAME FIRSTNAME RELATIONSHIP

HOMETELEPHONENUMBER MOBILENUMBER EMAILADDRESS

EMPLOYERINFORMATION EMPOLYERWORKNUMBER EXT

EMERGENCYCONTACTINFORMATIONLASTNAME1.

FIRSTNAME RELATIONSHIP

HOMETELEPHONENUMBER MOBILENUMBER HOMETELEPHONENUMBER

LASTNAME2.



LASTNAME3.



SIBLINGINFORMATION(STUDENTSATTENDINGSCHOOLSINHOBOKEN)RANKINFAMILY: NUMBEROFCHILDRENINFAMILY:NAME SCHOOL GRADE

NAME SCHOOL GRADE

NAME SCHOOL GRADE

ImakethisstatementwithfullknowledgethattheBoardofEducationofHoboken,NewJerseyisrelyinguponthetruthofthematterstatedherein.Iamawarethatifanystatement,whichIhavemadeaffidavit,isinaccurate,Iwillbesubjecttopunishmentinthematterprovidedbylaw.

PARENT/GUARDIAN’SNAME(PLEASEPRINT) PARENT/GUARDIAN’SSIGNATURE DATEFOROFFICEUSEONLYPHOTOGRAPH/PUBLICATIONPERMISSION YES⎕ NO⎕ INTERNETCONSENT YES⎕ NO⎕

ENTRYCODE ENTRYDATE EXITDATE

LUNCHAPPLICATIONSUBMITTEDYES⎕ NO⎕

HOMELANGUAGESURVEY:1. 2. 3. 4. 5. 6.

REGISTRATIONOFFICER

PRINTNAME SIGNATURE DATEOFAPPLICATION

EMERGENCY CARD HOBOKEN PUBLIC SCHOOLS

StudentID#______________________

LastName:______________________________First:________________________Initial:__________ DateofBirth(mm/dd/yyyy)___________________

Address:______________________________________________________________Apt#:__________ School:___________________________________

City:____________________________________________,State:________ZipCode:_____________ Grade:____________________________________

HomeTelephone:( )_______________________________________________________________ Teacher/Homeroom:_________________________

ToParent/Guardian(s):Toserveyourchildincaseofaccidentorsuddenillness,itisnecessarythatyouprovidethefollowingemergencycontactinformation:Name Address Telephone

Parent#1:__________________________________ Home:_______________________________Apt.___ Home#:_________________________________orGuardian#1_________________________________ Work:_____________________________________ Work#:_________________________________

Email:______________________________________Cell#:___________________________________

Parent#2:__________________________________ Home:_______________________________Apt.___ Home#:_________________________________orGuardian#2_________________________________ Work:_____________________________________ Work#:_________________________________

Email:_____________________________________ Cell#:_________________________________

Emergency:________________________________ Emergency:________________________________ Emergency:_____________________________Contact#1 Contact#2 Contact#3Relation:__________________________________ Relation:___________________________________ Relation:________________________________

Home#:___________________________________ Home#:___________________________________ Home#:_________________________________

Cell#:_____________________________________ Cell#:_____________________________________ Cell#:___________________________________DoesthischildhaveanyhealthInsurance,includingNJFamilyCare/Medicaid,Medicare,privateorother?Yes:______Ifyes,nameofinsurancecompany:_________________________________________________________________________________No:______Mychilddoesnothavehealthinsurance.

NJFamilyCareprovidesfreeorlowcosthealthinsuranceforuninsuredchildrenandcertainlowincomeparents.Formoreinformation,call(800)701-0710orvisitwww.njfamilycare.orgtoapplyonline.YoumayreleasemynameandaddresstotheNJFamilycareProgramtocontactmeabouthealthInsurance.Yes_____No_____

Signature:__________________________________PrintName:____________________________________Date:_______________Writtenconsentrequiredpursuantto20U.S.C.1232g(b)(1)and34C.F.R.99.30(b). Revised7/06/17


524 Park Avenue v Hoboken, NJ 07030 v 201.356.3619 v Fax: 201.792.5175



HOME LANGUAGE QUESTIONNAIRE

Please print

Child’s name: _______________________________________________________________ (First) (Middle) (Last)

Date of Birth: _____________________________________________

Person who is completing this questionnaire: ( ) Mother ( ) Father ( ) Grandparent ( ) Guardian ( ) Other

Please tell us about your child:

1. What language did the child first speak when he/she learned to talk?

English: [ ] Spanish: [ ] Other [Please specify language]: _____________________

2. What language does the family speak in the home the majority of the time?


3. What language does the person who primarily cares for the child speak most of the times?


4. What language does the child speak with the primary caregiver most of the times?


5. What language does the child speak with his/her siblings the majority of the time?


6. What language does the child speak with his/her friends most of the time?


7. Please list the preschool or daycare program your child has attended prior to this program?______________________________________________________________________

8. In what language would you prefer to receive information from the school?_____________________________________

9. What name do you call your child? (if different from above) ____________________________

Signature: ____________________________________________ Date: _________________

* Adapted from the sample survey in A Manual for Community Representatives of the Title VI Steering Committee, published on 9/76, by theInstitute of Cultural Pluralism, Lau General Assistance Center, San Diego University, San Diego, CA 92182

HOBOKEN BOARD OF EDUCATION STUDENT DATA / ENROLLMENT CLERK 524 Park Avenue v Hoboken, NJ 07030 v 201.356.3619 v Fax: 201.792.5175



BULLYING, INTIMIDATION AND HAZING POLICY

I have received a copy of the district bullying, intimidation and hazing policy. My child and I agree to its contents.

Parent/Guardian’s (Signature)

Student’s Name (Please print)

Teacher’s Name (Please print)

________________ ______________________ Grade Date





PARENTAL PERMISSION SLIP FOR WALKING FIELD TRIPS

Dear Parent/Guardian(s):

During the course of the school year the children enrolled in the Hoboken Public Schools will be participating in local activities to enhance their learning experiences. These activities will occur periodically during the course of the school day under the supervision of at least one certified teacher or supervisor. All necessary safety precautions shall be observed and the activities shall not exceed beyond the length of the school day. Students will be walking on these trips. Your signature below indicates that you are granting permission for your child to participate in all such excursions and activities during the course of the school year.

Student’s Name: (Print) _____________________________________ Grade: ______ (Last) (First) (MI)

Teacher’s Name: (Print) ________________________ Room: ____________________

Provider: _____________________School: ______________________________________

Parent/Guardian’s Name: (Print) _______________________________________________

Signature: _______________________________ Date: _____________________________





Student’s Photo/Video/Image and Other Personally Identifiable Information On the Internet Parent/Guardian Consent Form

Dear Parent(s)/Guardian(s):

In accordance with Statute 18A:36-35 (Disclosure of certain student information on Internet prohibited without parental consent), we are sending you this consent form to both inform you and to request permission for your child’s photo/video/image and other personally identifiable information to be published on the district and/or school’s website and/or social media. 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. Personally identifiable information includes student photos/videos/images, names, residential addresses, email addresses, phone numbers, and locations and times of class trips. If you, as parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the Principal of your child’s school, and such rescission will take effect upon receipt by the school.

Check one of the following choices: ☐ I/We GRANT permission for a photo/video/image that includes this student without any other personal identifiers to be published on the school and/or district’s website and/or social media. ☐ I/We GRANT permission for this student’s photo/video/image and name to be published on the school and/or district’s website and/or social media. ☐ I/We GRANT permission for this student’s photo/video/image and all other above-described personally identifiable information to be published on the school and/or district’s website and/or social media. ☐ I/We DO NOT GRANT permission for any photo/video/image that includes this student to be published on the school and/or district’s website and/or social media.

Student Name: (print) _____________________________________Grade________________ Parent/Guardian Name (print) ____________________________________________________ Parent/Guardian Relationship to Student: ____________________________________________ Parent/Guardian Signature_________________________________ Date__________________

HOBOKEN BOARD OF EDUCATION STUDENT DATA / ENROLLMENT CLER




Student’sSchoolWorkandPersonallyIdentifiableInformationOntheInternet

Parent/GuardianConsentForm

In accordance with Hoboken Board of Education‘s policies and procedures consistent with Statute 18A:36-35 (Disclosure of certain student information on Internet prohibited without parental consent) with additional regard to publication of your child’s school work on the district and/or school’s website and/or social media, also check one of the following choices: ☐ I/We GRANT permission for this student’s school work and photo/video/image to be published on the school and/or district’s website and/or social media. ☐ I/We GRANT permission for this student’s school work and photo/video/image and name to be published on the school and/or district’s website and/or social media. ☐ I/We GRANT permission for this student’s school work and photo/video/image and name and all other personally identifiable information to be published on the school and/or district’s website and/or social media. ☐ I/We GRANT permission for this student’s school work only to be published on the school and/or district’s website and/or social media without this student’s photo/video/image or any other personally identifiable information. ☐ I/We DO NOT GRANT permission for this student’s school work to be published on the school and/or district’s website and/or social media.

Student’s Photo/Video/Image for non-Internet purposes

Parent/Guardian Consent Form

In accordance with Hoboken Board of Education‘s policies and procedures with regard to use of your child’s photo/video/image for purposes unrelated to the Internet, please also indicate your preferences below. I/We GRANT permission for use of this student’s photo/video/image as follows (check all that apply): ☐ For instructional use in the classroom ☐ For use within the student’s school building ☐ For use in the yearbook ☐ For use in district publications ☐ For use in print and broadcast media (i.e., newspapers, television, etc) Thank you for your cooperation with Hoboken Board of Education in our effort to protect your child’s right to privacy consistent with your specific preferences as Parent/Guardian.

UNIVERSALCHILD HEALTH RECORD

Endorsed by: American Academy of Pediatrics, New Jersey ChapterNew Jersey Academy of Family PhysiciansNew Jersey Department of Health and Senior Services

SECTION I - TO BE COMPLETED BY PARENT(S)Child’s Name (Last) (First) Gender

Male FemaleDate of Birth

/ /Does Child Have Health Insurance?

Yes NoIf Yes, Name of Child's Health Insurance Carrier

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

I give my consent for my child’s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form.Signature/Date This form may be released to WIC.

Yes No

SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDERDate of Physical Examination: Results of physical examination normal? Yes No

Weight (must be takenwithin 30 days for WIC)Height (must be takenwithin 30 days for WIC)Head Circumference(if <2 Years)

Abnormalities Noted:

Blood Pressure(if >3 Years)

IMMUNIZATIONS Immunization Record Attached Date Next Immunization Due:

MEDICAL CONDITIONSChronic Medical Conditions/Related Surgeries• List medical conditions/ongoing surgical

concerns:

None Special Care PlanAttached

Comments

Medications/Treatments• List medications/treatments:


Comments

Limitations to Physical Activity• List limitations/special considerations:


Comments

Special Equipment Needs• List items necessary for daily activities


Comments

Allergies/Sensitivities• List allergies:


Comments

Special Diet/Vitamin & Mineral Supplements• List dietary specifications:


Comments

Behavioral Issues/Mental Health Diagnosis• List behavioral/mental health issues/concerns:


Comments

Emergency Plans• List emergency plan that might be needed and

the sign/symptoms to watch for:


Comments

PREVENTIVE HEALTH SCREENINGSType Screening Date Performed Record Value Type Screening Date Performed Note if Abnormal

Hgb/Hct HearingLead: Capillary Venous VisionTB (mm of Induration) DentalOther: DevelopmentalOther: Scoliosis

I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared toparticipate fully in all child care/school activities, including physical education and competitive contact sports, unless noted above.

Name of Health Care Provider (Print)

Signature/Date

Health Care Provider Stamp:

CH-14 SEP 08 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider

CH-14 (Instructions)SEP 08

Instructions for Completing the Universal Child Health Record (CH-14)

Section 1 - ParentPlease have the parent/guardian complete the top section andsign the consent for the child care provider/school nurse todiscuss any information on this form with the health careprovider.

The WIC box needs to be checked only if this form is beingsent to the WIC office. WIC is a supplemental nutritionprogram for Women, Infants and Children that providesnutritious foods, nutrition counseling, health care referrals andbreast feeding support to income eligible families. For moreinformation about WIC in your area call 1-800-328-3838.

Section 2 - Health Care Provider1. Please enter the date of the physical exam that is being

used to complete the form. Note significant abnormalitiesespecially if the child needs treatment for that abnormality(e.g. creams for eczema; asthma medications forwheezing etc.)• Weight - Please note pounds vs. kilograms. If the

form is being used for WIC, the weight must havebeen taken within the last 30 days.

• Height - Please note inches vs. centimeters. If theform is being used for WIC, the height must havebeen taken within the last 30 days.

• Head Circumference - Only enter if the child is lessthan 2 years.

• Blood Pressure - Only enter if the child is 3 yearsor older.

2. Immunization - A copy of an immunization record maybe copied and attached. If you need a blank form onwhich to enter the immunization dates, you can request asupply of Personal Immunization Record (IMM-9) cardsfrom the New Jersey Department of Health and SeniorServices, Immunization Program at 609-588-7512.• The Immunization record must be attached for the

form to be valid.• “Date next immunization is due” is optional but helps

child care providers to assure that children in theircare are up-to-date with immunizations.

3. Medical Conditions - Please list any ongoing medicalconditions that might impact the child's health and wellbeing in the child care or school setting.

a. Note any significant medical conditions or majorsurgical history. If the child has a complexmedical condition, a special care plan should becompleted and attached for any of the medicalissue blocks that follow. A generic care plan(CH-15) can be downloaded atwww.state.nj.us/health/forms/ch-15.dot or pdf. Hardcopies of the CH-15 can be requested from theDivision of Family Health Services at 609-292-5666.

b. Medications - List any ongoing medications.Include any medications given at home if they mightimpact the child's health while in child care (seizure,cardiac or asthma medications, etc.). Short-termmedications such as antibiotics do not need to belisted on this form. Long-term antibiotics such asantibiotics for urinary tract infections or sickle cellprophylaxis should be included.

PRN Medications are medications given only asneeded and should have guidelines as to specificfactors that should trigger medication administration.

Please be specific about what over-the-counter(OTC) medications you recommend, and includeinformation for the parent and child care provider asto dosage, route, frequency, and possible sideeffects. Many child care providers may requireseparate permissions slips for prescription and OTCmedications.

c. Limitations to physical activity - Please be asspecific as possible and include dates of limitationas appropriate. Any limitation to field trips should benoted. Note any special considerations such asavoiding sun exposure or exposure to allergens.Potential severe reaction to insect stings should benoted. Special considerations such as back-onlysleeping for infants should be noted.

d. Special Equipment – Enter if the child wearsglasses, orthodontic devices, orthotics, or otherspecial equipment. Children with complexequipment needs should have a care plan.

e. Allergies/Sensitivities - Children with life-threatening allergies should have a special careplan. Severe allergic reactions to animals or foods(wheezing etc.) should be noted. Pediatric asthmaaction plans can be obtained from The PediatricAsthma Coalition of New Jersey at www.pacnj.orgor by phone at 908-687-9340.

f. Special Diets - Any special diet and/or supplementsthat are medically indicated should be included.Exclusive breastfeeding should be noted.

g. Behavioral/Mental Health issues – Please noteany significant behavioral problems or mental healthdiagnoses such as autism, breath holding, orADHD.

h. Emergency Plans - May require a special care planif interventions are complex. Be specific aboutsigns and symptoms to watch for. Use simplelanguage and avoid the use of complex medicalterms.

4. Screening - This section is required for school, WIC,Head Start, child care settings, and some otherprograms. This section can provide valuable data forpublic heath personnel to track children's health. Pleaseenter the date that the test was performed. Note if thetest was abnormal or place an "N" if it was normal.• For lead screening state if the blood sample was

capillary or venous and the value of the testperformed.

• For PPD enter millimeters of induration, and thedate listed should be the date read. If a chest x-raywas done, record results.

• Scoliosis screenings are done biennially in thepublic schools beginning at age 10.

This form may be used for clearance for sports orphysical education. As such, please check the box abovethe signature line and make any appropriate notations inthe Limitation to Physical Activities block.

5. Please sign and date the form with the date the form wascompleted (note the date of the exam, if different)• Print the health care provider's name.• Stamp with health care site's name, address and

phone number.

PHYSCIAL EXAMINATION K-12

Student's Name:-,-_____________ Date of Birth:. _______ _Height: __ . Weight: __ Pulse: __ BP ___ _

Vision: R 20/ L20/ __ Corrected: Y __ N __ Hearing: R __ L __

MEDICAL NORMAL ABNORMAL . INITIALS

Appearance

Eyes/ ears/nose/throat

Lymph .nodes '

Heart

Pulses

Lungs

Abdomen

Genitalia (males only)

Skin

Musculoskel eta!

Neck '

Sack '

Shoulder/arm

Elbow/forearm

Wrist/hand '

Hip/thigh

Knee

Leg/ankle

Foot

Recommendations: ______________ ---'------�----

Physician's Name: ________________ Date: ______ _

Address: ___________ ____c _______________ _

City: ____________ State: ______ Zip Code: _____ _

Physician's Signature: _____________________ MD/DO/NP·

*PARENTS MUST PROVIDE THE BOLD ITMES IN ORDER TO REGISTER A STUDENT

(Form 6b)

Documents

K-12 Student Registration Packet - Hoboken Public …[email protected] Where Students Come First PLEASE COMPLETE ALL REGISTRATION FORMS. Requirements for Registration: Child