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The Registration Process
Print and complete all registration documents and bring them to
the Franklin
Township Board of Education office of Student Registration
located at 1755 Amwell
Road, Somerset, New Jersey along with the items listed
below.
1. A valid birth certificate/passports are acceptable (cannot be
expired)
2. Two Proofs of Residency in Franklin Township (a combination
of the following: current lease, deed, mortgage statement, property
tax statement and a utility bill-
PSEG, Water, Sewer) If you are living with someone in the
district, you must
print and complete a Residency Affidavit and have it notarized.
In addition
to the Residency Affidavit you must supply proof that the
individual listed as
the homeowner or tenant is a Franklin resident. You must bring
two forms
of residency documentation for the homeowner or tenant and one
for the
parent/guardian registering the student.
3. Proof of all updated immunization records (please note that
all immunizations must be signed or stamped from the doctors office
to be considered official)-
As per New Jersey Administrative Code Citation 8:57-4.2-A
principal,
director or other person in charge of a school, pre-school, or
child care
facility shall not knowingly admit or retain any child whose
parent or
guardian has not submitted acceptable evidence of the childs
immunization,
according to the schedules specified in this subchapter. 4.
Last/most recent Report Card, Transcript of grades, credits earned,
State
I.D.# (if transferring from a NJ public school), and
standardized test results
such as (GEPA, Terra Nova, etc.). Although the former school
district is expected
to forward academic information to the new school district upon
notification of
enrollment, it is helpful if copies of standardized test scores
and the latest report
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card are presented at the time of registration. Please be
prepared to share the
name, address and phone number of your child's former
school.
5. Photo Identification for parent or guardian registering the
child.
6. If you are not the parent or legal guardian of the child, you
must provide proof of
guardianship established by NJ Surrogate Court or DYFS
placement.
7. If your child is or has been evaluated by any Special
Education Committee, you
must bring the most recent copy of the childs IEP (Individual
Educational Plan)
Note: After the registration process has been completed, our
office will notify the Transportation Office and you should receive
information from them stating your childs eligibility for bus
service. If you have any questions regarding the registration
process, please contact the Parent Information Center/Office of
Student Registration.
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Franklin Township Public Schools1755 Amwell RoadSomerset, NJ
08873Registration FormSmiD#:
Student Information/Information del Estudiante:
Gender: D Male/Hombre D Female/Mujer
State ID#:
Birth Date/Fecha de Nacimiento:
Last Name/Apellido First Name/Nombre Middle Initial/Segundo
Nombre
Address/Direccidn
Birth Place/Lugar de Nacimiento:
City/State/Ciudad/Estado Zip Code/Codigo Postal
City/State or Country/ Ciudad/Estado o Pals
Is the student receiving Special Education Services? Esta el
niflo (a) recibiendo Servicios de Educacion Especial?Yes/Si No
Ethnicity/Grupo Etnico (check all that apply/seleccionar todo
que aplique):D American Indian or Alaska Native/Indio Americano o
Nativo de Alaska ~ Asian/Asiatico D Black or African
American/Afro-Americano Hispanic/Hispano j Native Hawaiian or Other
Pacific Islander/Nativo de Hawai o Otro Nativo de las Islas
Pacificas White/Blanco
Parent/Guardian Information:Informacton del Padre/Guardian:
Last Name/Apellido First Name/Nombre Relationship/Relacion
Address if different from above/Direcci6n si es diferente
City/State/Ciudad/Estado
Phone #'&:
Zip Code/Codigo Postal
# De TeleTonos: Home/Casa Work/Trabajo Cell/Celular Email/Correo
Electrtinico
Check here if the person listed above should be or is the
Emergency Contact LSeleccionar la caja, si la persona nombrada
arriba es o deberia ser el Contacto de Emergencia
Last Name/Apellido First Name/Nombre Relationship/Relacion
Address if different from above/Direcci6n si es diferente
City/State/Ciudad/Estado
Phone #'s:
Zip Code/C6digo Postal
# De TeleTonos: Home/Casa Work/Trabajo Cell/Celular Email/Correo
Electrdnico
Additional Information:Please list Siblings and School they
attend:Favor de listar a hermanos (as) y la escuela que
asisten:
Last Name/Apellido
Last Name/Apellido
Last Name/Apellido
First Name/Nombre
First Name/Nombre
First Name/Nombre
School/Escuela
School/Escuela
School/Escuela
High School Students/Estudiantes de Escuela Secundaria:
What year did the child graduate from 8th grade?En que ano se
graduo el nino (a) de primaria o 8vo grado?
Has your child ever attended a High School? Ha asistido su hijo
(a) a una Escuela Secundaria?Yes/Si NoIf so, what is the Name? Cual
es el nombre de la escuela? state/estado? que aflo?
Is your child in any vocational program or plans to be in one?
Esta su hijo (a) en algiin programa vocacional o esta planeando
asistir a uno?Yes/Si No
Parent/Guardian Signature/ Firma del Padre/Guardian:
OFFICE USE ONLYSchool AssignmentPrior SchoolTransfer Code
Current GradeSchool ID
Transfer Card? YGNjBirth Certificate? YONuReturning Student Y D
N DTransportation Notified? YDND
Residence Documentation? YDNuGuardianship Documentation?
YCNi]Free or Reduced Lunch? YDND
Verification of Birth Date? Y N ~jIs this a "bona fide change of
residence? Y N D
Registration Completed By: Registration Date:
GEPEATICKSticky NoteMigrationNone set by GEPEATICK
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Franklin Township Public SchoolsPreK-12 Home Language Survey
Student Information (Please Print) Student ID#:First Name Last
Name Date ot Birth Genaer
D Female D MaleCountry of Birth Date ofbntry in U.S. Date first
enrolled in any U.S. school Ethnicity
D White Black D Latino AsianD Pacific Islander D American
Indian
School Information (To be completed by office personnel)School
Current tirade Enrollment Date Evaluated by: (Bilingual / fcJSL
Teacher)
Date WAPT Placement Exam was
administered
Primary Language
Eligibility - Based on the WAPT Placement Exam results, the
student is:
D Not eligible for ESL / Bilingual Services Eligible for ESL
services only (Date placed into program) Eligible for Bilingual and
ESL services (Date placed into program)
In which language do you wish to receive
school communication? English Spanish Gujarati
Questions for Parents / Guardians (Please Print)1
2
3
4
5
6
7
8
9
Who is the person completing the survey?
What language did the child learn when he/she first began to
talk?
What language does the family speak at home most of the
time?
What language does the mother [guardian] speak to the child most
of thetime?What language does the father [guardian] speak to the
child most of thetime?
What language does the child speak to his/her mother most of the
time?
What language does the child speak to his/her father most of the
time?
What language does the child speak to her/her brothers and
sisters mostof the time?What language does the child speak to
his/her friends most of the time?
Response Mother Father D Grandparent Guardian Other
D English D Spanish D Gujarati OtherD English D Spanish D
Gujarati Other
D English D Spanish D Gujarati OtherD English D Spanish D
Gujarati Other
D English D Spanish D Gujarati OtherD English D Spanish D
Gujarati Other
D English D Spanish D Gujarati OtherD English D Spanish D
GujaratiD Other
Please list any previous schooling1
2
Name ot School
Grades Completed
Name ot School
Grades Completed
Dates ot Attendance
Dates ot Attendance
Location (City / Country)
Language ot Instruction
Location (City / Country)
Language ot Instruction
Previous ESL / Bilingual ProgramSchool Grades Attended Dates
Attended
Signature:
White - Director
(Person completing this survey)
Canary - ESL Teacher
Date:
Pink - School
(today's date)
Franklin Township Public Schools
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FRANKLIN TOWNSHIP PUBLIC SCHOOLSSomerset (Somerset County), New
JerseyHome Contact / Emergency School Closing Contact Card - School
YearStudent's Last Name First Name Middle Name Grade
Teacher
RELATIONSHIP - MOTHER / GUARDIAN
Last Name First Name
Address
Telephone
Middle Name
City
Alt. Telephone Ext.
Title
State Zip Code
Birthdate (optional)
Employer
Work Address
Work Telephone Ext. Work HoursFrom
City Stale
To
Zip Code
E-mail Address:
RELATIONSHIP- FATHER /GUARDIAN
Last Name First Name
Address
Telephone
Middle Name
City
Alt. Telephone Ext.
Title
State Zip Code
Birthdate (optional)
Employer
Work Address
Work Telephone Ext. Work HoursFrom
City State
To
Zip Code
E-mail Address:
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Student's Last Name First Name Middle Name
OTHER CONTACTSList two alternative people who have agreed to
assume lull responsibility for your child as defined in the
Emergency SchoolClosing Standard Operating Procedure.
First Contact
Address
Telephone Ext.
City-
Secondary Contact
Address
Relationship to Student
State
Telephone Ext.
City
Zip Code
Relationship to Student
State Zip code
EMERGENCY CONTACTS - IN CASE WHERE PARENT (S) CANNOT BE REACHED,
PLEASE LIST ALTERNATE.
Medical Alert 1 Medical Alert 2
Physician Telephone Ext.
Does your child have medical insurance? Yes No
Can you be contacted by New Jersey Family Care? Yes No
If none of the above can reached, what do you wish the school to
do in case your child is sick or injured?Please Complete:
* (It is understood that in the final disposition of an
emergency case, the judgment of the school authorities will
prevail. TheRecommendation of the parent as indicated above will be
respected as far as possible.
My child is NOT capable of self-care in the event of an
Emergency School Closing. l want to be called: M do not need to be
called.
Signature: Mother/Guardian: Father/Guardian:
Bus No: __ or Walker. If your child is in an after school
program, indicate the name of the program:
Phone number:
If there is a legal separation in the family, the school
district requires legal documentation that indicates which of the
parentsHas legal custody of the child. In the absence of such
documentation, the school district will honor the custodial rights
ofeither parent. Please complete the remainder of this section, if
applicable.
Yes, there is a legal separation (please check) Q
Parent has submitted for review appropriate documentation to the
principal that indicates which parent may or may not signthe child
out of school and/or have access to records.
Parent/ Guardian Signature: Date:
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Franklin Township Public Schools 1755 Amwell Road, Somerset, NJ
08873
Tel: (732)-873-2400 ext 401; Fax: (732) 873-8393 Parent
Information Center/Office of Student Registration
The child whose name appears below has registered at a school
within our school district. Will you please send cumulative
records, health records, test records, psychological reports, and
any additional information you may have concerning their progress
to the school indicated below. Thank you for your cooperation.
Childs Name: __________________________________________ Previous
Grade: _______
PARENTS CONSENT FOR TRANSFER OF RECORDS
The ____________________________________________ School District
has my permission to (DISTRICT TRANSFERRING FROM) transfer the full
student (s) records, including achievement, behavioral and
psychological, for ALL students listed above to Franklin Township
Public Schools. I understand that I may review these records, in
accordance with the provisions of the Family Educational Rights and
Privacy Act of 1974.
_______________________________________________________________________________________
ADDRESS OF PREVIOUS SCHOOL Signature of Parent/Guardian
_________________________________________ Date________ Print Name
of Parent/Guardian
__________________________________________________
*PLEASE SEND STUDENT RECORDS TO THE FOLLOWING SCHOOL*
Conerly Road School-Grade PK-4
C.V Bush - Secretary 35 Conerly Road, Somerset, NJ. 08873 (P)
732-249-9362 (F) 732-247-7076
MacAfee Road School-Grade PK-4 Patsy Hooper - Secretary
53 MacAfee Road Somerset, NJ. 08873 (P) 732-249-9097 (F)
732-247-1408
Elizabeth Ave School-Grade PK-4 Pat Sanchez - Secretary
363 Elizabeth Ave Somerset, NJ. 08873 (P) 732-356-0113 (F)
732-271-2534
Pine Grove Manor School-Grade PK-4 Sharon Pron - Secretary
130 Highland Avenue Somerset, NJ. 08873 (P) 732-246-2424 (F)
732-843-5572
Franklin Park School-Grade PK-4 Judy Nocero - Secretary
30 Eden Street, Franklin Park, NJ. 08823 (P) 732-297-5666 (F)
732-297-5834
Sampson G. Smith School Grade 5-6 Michelle Moskal -
Secretary
1649 Amwell Road Somerset, NJ. 08873 (P) 732-873-2800 (F)
732-873-0451
Franklin Park Annex/ child Develop. Center Jo-Ann Piagentinni -
Secretary
1 Central Avenue Franklin Park, NJ. 08823 (P) 732-297-3427 (F)
732-940-8931
Franklin Middle School Grade 7-8 Noreen Leib-Secretary
415 Francis Street Somerset, NJ.08873 (P) 732-249-6410 (F)
732-246-0770
Hillcrest School-Grade PK-4 Terri Levy & Luisa Flintoff -
Secretary
500 Franklin Blvd Somerset, NJ. 08873 (P) 732-246-0170 (F)
732-247-8405
Franklin High School Grade 9-12 Patricia Naulty & Evelyn
Pemberton Secretary
500 Elizabeth Avenue Somerset, NJ. 08873 (P) 732-302-4200 (F)
732-302-4212
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Franklin Township Public Schools 1755 Amwell Road, Somerset, NJ
08873
Tel: (732)-873-2400 ext 401; Fax: (732) 873-8393 Parent
Information Center/Office of Student Registration
Pierina De La Cruz, Coordinador of Parent Information Center The
child whose name appears below has registered at a school within
our school district. Will you please send cumulative records,
health records, test records, psychological reports, and any
additional information you may have concerning their progress to
the school indicated below. Thank you for your cooperation. Nombre
del Nio (s): __________________________________________ Grado
Previo: ____
CONSENTIMIENTO DE PADRES PARA INTERCAMBIO DE ARCHIVOS
El Distrito Escolar de
__________________________________________ tiene (El DISTRITO
PREVIO)
mi autorizacin para Intercambiar los archivos del estudiante
(s), incluyendo reportes de progreso, comportamiento y psicolgico,
para TODOS los estudiantes nombrado anteriormente al Distrito
Escolar del Municipio de Franklin. Yo entiendo que yo puedo revisar
estos archivos, acordados en las provisiones de los Derechos
Educacionales de Familias y El Acto de Privacidad del 1974.
_____________________________________________________________________
DIRECCIN DE ESCUELA PREVIA Firma del Padre/Guardin
__________________________________ Fecha ________ Escribir el
Nombre del Padre/Guardin ______________________________________
*PLEASE SEND STUDENT RECORDS TO THE FOLLOWING SCHOOL*
Conerly Road School- Grade PK-4 Donna Lucash & C.V Bush -
Secretary
35 Conerly Road, Somerset, NJ. 08873 (P) 732-249-9362 (F)
732-247-7076
MacAfee Road School-Grade PK-4 Fee Valeri Stark & Patsy
Hooper - Secretary
53 MacAfee Road Somerset, NJ. 08873 (P) 732-249-9097 (F)
732-247-1408
Elizabeth Ave School-Grade PK-4 Janet Flissar & Pat Sanchez
-Secretary 363 Elizabeth Ave Somerset, NJ. 08873
(P) 732-356-0113 (F) 732-271-2534
Pine Grove Manor School-Grade PK-4 Sharon Pron - Secretary
130 Highland Avenue Somerset, NJ. 08873 (P) 732-246-2424 (F)
732-843-5572
Franklin Park School-Grade PK-4 Judy Nocero & Rosetta
Stevenson -Secretary
30 Eden Street Franklin Park, NJ. 08823 (P) 732-297-5666 (F)
732-297-5834
Sampson G. Smith School Grade 5-6 Michelle Moskal & Debra
Hentz - Secretary 1649 Amwell Road Somerset, NJ. 08873
(P) 732-873-2800 (F) 732-873-0451
Franklin Park Annex/ child Develop. Center Jo-Ann Piagentinni -
Secretary
1 Central Avenue Franklin Park, NJ. 08823 (P) 732-297-3427 (F)
732-940-8931
Franklin Middle School Grade 7-8 Noreen Leib-Secretary
415 Francis Street Somerset, NJ.08873 (P) 732-249-6410 (F)
732-246-0770
Hillcrest School-Grade PK-4 Terri Levy & Luisa Flintoff -
Secretary
500 Franklin Blvd Somerset, NJ. 08873 (P) 732-246-0170 (F)
732-247-8405
Franklin High School Grade 9-12 Patricia Naulty & Evelyn
Pemberton Secretary
500 Elizabeth Avenue Somerset, NJ. 08873 (P) 732-302-4200 (F)
732-302-4212
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Franklin Township Public Schools Parent Information
Center/Centro de Informacion Para Padres
1755 Amwell Road, Somerset, NJ 08873 Tel: (732) 873-2400; Fax:
(732) 873-8393
Parent Affidavit of Residency/Declaracion Jurada de
Residencia
If a parent is subletting an apartment or home, or if more than
one family shares a living space and there is only one leaseholder
or homeowner, the parent must present a notarized Address Affidavit
signed both by the primary leaseholder as well as the parent
affirming that the family is residing in this home, and must attach
the lease, and/or utility bill (PSEG). Si un padre no tiene
contrato de alquiler, o ms de una familia comparten una vivienda y
hay un solo dueo/a, el padre tiene que presentar este formulario
notariado Declaracin Jurada firmado por el dueo/a y el padre
afirmando que la familia reside en esta direccin, adjunto debe
estar el contrato de alquiler del dueo/a o cuenta de
electricidad.
Section A: Students Information/Informacion del Estudiantes-
Print/Letra de Molde
LAST NAME/APELLIDO NAME/NOMBRE GENDER/SEXO DOB/FECHA DE NACI. 1.
2. 3. 4. 5.
Section B:Parent/Guardian Information/Informacion del Padre-
Print/Letra de Molde PARENTS LAST NAME/APELLIDO DEL PADRE
NAME/NOMBRE PARENTS CURRENT ADDRESS/DIRECCION DEL PADRE HOME
PHONE/# DE LA CASA WORK PHONE/# DE TRABAJO CELL PHONE
Section C: Owner, Leaseholder/Dueo/a, o Inquilino
Primario-Print/Letra de Molde OWNERS LAST NAME/APELLIDO FIRST
NAME/APELLIDO OWNERS CURRENT ADDRESS/DIRECCION ACTUAL DEL DUENO
HOME PHONE/# DE LA CASA WORK PHONE/# DE TRABAJO CELL PHONE
RELATIONSHIP TO PARENT/RELACION AL PADRE
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To be completed by parent/Para ser completado por el padre: I,
_______________________________, the parent of
___________________________ Yo , el padre de (Nombre del
Estudiante) hereby affirm that I am residing with
_________________________________________ afirmo que resido con at
the following address
____________________________________________________ en la
siguiente direccin I understand that Franklin Township Public
Schools has the right to conduct an Attendance Investigation to
verify my residence including a visit to the home of the primary
leaseholder. I also understand that registration in school is based
on eligibility determined by my residence, and Franklin Township
Public Schools has the right to transfer students for whom
falsified documentation was provided at the time of registration.
In the event that my residency changes, I agree to notify the
district and present new proof of address. Yo entiendo que Las
Escuelas Publicas del Municipio de Franklin tienen el derecho de
conducir una investigacin de asistencia incluyendo una visita a la
vivienda del dueo/a. Yo tambin entiendo que la inscripcin esta
basada en la elegibilidad determinada por donde vivo, y que el
distrito tiene el derecho de transferir cualquier estudiante que se
halla provedo falsa documentacin al tiempo de inscripcin. Si mi
residencia cambia, yo soy responsable de informarles y someter
nueva prueba de direccin. To be completed by Primary
Leaseholder/Owner: Para ser completado por el Dueno/a: I hereby
affirm
that______________________________________________________________
Yo afirmo que (Name of Parent and Child-ren) (Nombre del Padre y
Estudiante-s) are residing with me at
___________________________________________________________ residen
conmigo en (insert address) (direccin) I understand that Franklin
Public Schools has the right to conduct an Attendance Investigation
to verify the residence of the parties named in this affidvit,
including a visit to my home and interviews with my neighbors. I
can be contacted at the number (s) listed below should the District
require further information. Yo entiendo que Las Escuelas Publicas
del Municipio de Franklin tienen el derecho de conducir una
investigacin de asistencia para la verificacin de vivienda de las
personas nombradas en esta declaracin incluyendo una visita a mi
hogar e interrogar a mis vecinos. Me pueden contactar en los nmeros
de telfonos enlistados aqu si el distrito necesita ms informacin.
Signatures/Firmas: Parent Signature/Firma del Padre:
_____________________________________________ Primary
Leaseholder/Firma del Dueo/a:
__________________________________________ State of New Jersey SS:
County of __________________________________ Sworn to before me
this ___________ day of _________________________, Year ___________
____________________________________________________ Notary
Public
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FRANKLIN TOWNSHIP PUBLIC SCHOOLS NJ Family Care Health
Insurance
Dear Parent/Guardian: More than a quarter-million New Jersey
children lack health insurance, and that number is likely to grow
as the economy deteriorates. If our child does not have health
insurance you may qualify for low cost or no cost health insurance
through the NJ FamilyCare Program. NJ FamilyCare is not a welfare
program, but rather the State of New Jerseys way of providing
affordable health coverage for kids and certain low-income parents.
NJ FamilyCare is a federal and state funded health insurance
program created to help New Jerseys uninsured children and certain
low-income parents and guardians to have affordable health
coverage. NJ FamilyCare is for families who do not have available
or affordable employer insurance, and cannot afford to pay the high
cost of private health insurance. How to qualify can be viewed in
12 languages, and the entire application process can be completed
by mail or online. All enrollment packets contain postage free
envelopes. To find out if you qualify for NJ FamilyCare call
1-800-701-0710, for hearing impaired individuals TTY
1-800-701-0720. Multi-lingual operators are available and calls are
accepted Mondays and Thursdays between 8:00 a.m. & 5:00 p.m.
You may also apply online at www.njfamilycare.org. NJ FamilyCare
Advantage is another low cost health insurance program offered
through Horizon NJ Health that your family may be eligible for. To
qualify you must meet the following guidelines:
Without health insurance for more than six months Your children
must be under the age of 19 Eligibility id based upon household
income and the number of people in your
family If you have questions about the NJ FamilyCare Advantage
program call the Horizon NJ Health Outreach Center at
1-800-637-2997. You may call toll free from 8:00 a.m. until 7:00
p.m. Monday through Friday. You may access the NJ FamilyCare
Advantage program online at www.horizonnjhealth.com as well. You
may also contact your school nurse for any questions or assistance
regarding healthcare insurance for your child.
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IMM-19 (Side 1)SEP 06
New Jersey Department of Health and Senior ServicesVaccine
Preventable Disease Program
PO Box 369Trenton, NJ 08625-0369
ANNOUNCINGTHE NEW JERSEY IMMUNIZATION INFORMATION SYSTEM
(NJIIS)
To New Jersey Parents and Guardians:
In order to attend any licensed day care, preschool, public,
parochial or private school in NewJersey, your child must meet
state mandated immunization requirements. A record of
theseimmunizations, supplied by your healthcare provider, is
maintained by the school on a stateapproved form (A45). This record
is essential for admission to any new school to which your
childtransfers, for entrance into high school and for college
entrance. The New Jersey ImmunizationInformation System (NJIIS) has
been developed to provide a confidential population-basedelectronic
database that collects and stores vaccination data for New Jersey
residents. This registryis already in use at more than 400 sites
throughout New Jersey, with more than 600,000 patientrecords
currently in the system. The immunization Information System is the
first step in creatingelectronic health records for New Jersey
school students.
New Jersey public schools are assisting in this project by
inputting data from the studentsImmunization Record. Participation
in this program is free and will provide you with a permanentrecord
of your childs immunizations, as well as reminders of the need for
any additional doses. Itwill exist for your child long after
graduation when immunization records may be needed for
foreigntravel or other situations. It will be available to you for
summer camp requirements and should youchange healthcare
providers.
Your childs immunization record is confidential. It is available
only to you, the Health Departmentand its related service agencies
(your childs school) and the health provider(s) you choose. If
youchange providers, only the new provider will be able to send you
reminders.
To enroll in the system, simply sign the consent form on the
back of this letter and return it to yourchilds school nurse within
seven days.
If you have any questions, you may call your childs school
nurse.
We hope that you will take advantage of this opportunity to
promote the well being of your child.
PLEASE COMPLETE THE REVERSE SIDE OF THIS SHEET ANDRETURN IT TO
YOUR CHILDS SCHOOL NURSE!
- OVER -
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IMM-19 (Side 2) SEP 06
NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)
CONSENT TO PARTICIPATE
CHILD INFORMATION (please print) PARENT/GUARDIAN INFORMATION
Name
Name
Date of Birth
Relationship
Address
Address
I have read the information about the New Jersey Immunization
Information System (NJIIS) and understand that the purpose of this
program is to keep a central record of my childs immunization
history and to remind me when immunizations are due. I understand
that I can obtain a copy of my childs record from my medical
provider, my local health department, or my childs school
nurse.
There is no cost to participate in this program.
Yes, I would like to participate in this program.
No, I do not wish to participate in this program.
Signature of Parent / Guardian
Date
New Jersey Department of Health and Senior Services Vaccine
Preventable Diseases Program
PO Box 369 Trenton, NJ 08625-0369
PLEASE RETURN THIS FORM TO YOUR CHILDS SCHOOL NURSE WITHIN 7
DAYS
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FRANKLIN TOWNSHIP PUBLIC SCHOOLS Nursing Services/Servicios de
Salud
Date/Fecha: _______________________ Dear Parent/Guardian: There
have been new laws enacted to protect the privacy of student health
information. In order to be in compliance with the Family
Educational Rights and Privacy Act (FERPA), we must have the
parents/guardians permission to share medically related information
with appropriate staff members at the school. This medically
related information would include, but would not be limited to,
information on allergies, history of asthma, medication,
hearing/vision problems, seizures, etc. This confidential
information would be shared only with appropriate staff members
with the intent of making them aware of any potential problems that
may arise while your child is in school. ___________ I give
permission to share my childs medical information. ___________ I do
not want to share my childs medical information. Student Name
________________________________________________ Parent/Guardian
Signature _________________________________________________
Estimado Padre/Guardian: Una ley ha sido promulgada para proteger
la privacidad de informacin de salud de todo estudiante. Para
nosotros obedecer con (FERPA) Family Education Rights and Privacy
Act, nosotros necesitamos permiso de los padres/guardianes para
compartir informacin medica con los empleados apropiados de la
escuela. Esta informacin medica puede incluir, pero no es limitada
a, informacin sobre alergias, historial de asma, medicamentos,
problemas de odos o de la vista, convulsiones o ataques, etc. Esta
informacin confidencial ser compartida solamente con los empleados
apropiados con la intencin de informarles de algn problema que
pueda ocurrir mientras su hijo/a esta en la escuela. __________ Yo
doy permiso para compartir informacin mdica de mi hijo/a.
__________ Yo no doy permiso para compartir informacin mdica de mi
hijo/a. Nombre del Estudiante
______________________________________________ Firma del
Padre/Guardin ______________________________________________ Rev.
01/09
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TO BE COMPLETED BY PARENT
FRANKLIN TOWNSHIP PUBLIC SCHOOLS Health Appraisal Form
Name_________________________________________________________ M(
) F( ) Grade_______ Age_____ (Last) (First) (Middle)
Address_______________________________________________________
Phone (______) _________________
DOB_________________________________ Place of
Birth___________________________________________ (Month) (Day)
(Year) Where is the student coming from? Within NJ
____________________________(which school in NJ) Out of State
_________________(which state) Out of country ____________________
(which country) Fathers Name__________________________________
Employer/Phone________________________________ Mothers
Name_________________________________
Employer/Phone_________________________________
Guardian_______________________________________Employer/Phone_________________________________
EMERGENCY CONTACT PERSON AND
NUMBER________________________________________________ FAMILY
PHYSICIAN/CLINIC_____________________________________
PHONE______________________ LANGUAGE SPOKEN AT
HOME_______________________________________________________________
CHILDREN IN FAMILY Name DOB Name DOB
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
HEALTH HISTORY DISEASE HISTORY TYPE/YEAR DISEASE HISTORY
TYPE/YEAR Allergies Diabetes Drug Sensitivities Heart Disease Lyme
Disease Otitis Media Hepatitis Rheumatic Fever Neuromuscular
Disease Strep Infections Asthma Mononucleosis Chicken Pox Vision
Disorder Convulsive Disorder Hearing Disorder ADHD Congenital
Defects OPERATION/INJURIES (PLEASE SPECIFY): 1. 2. 3.
MEDICATIONS:___________________________________________________________________________________________________________________________________________________________________________
ALLERGIES:
Drug_________________________________________________________________________________________
Environmental_________________________________________________________________________________
Food_________________________________________________________________________________________
Speech
Problems______________________________________________________________________________________
Date__________________________ Parent/Guardian
Signature______________________________________
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FRANKLIN TOWNSHIP PUBLIC SCHOOLS
STUDENT HEALTH AND PHYSICAL EXAM FORM
TO BE COMPLETED BY FAMILY PHYSICIAN OR PEDIATRICIAN
Students Name: Birth Date:
Sex: Male Female
DISEASE HISTORY TYPE/YEAR DISEASE HISTORY TYPE/YEAR Allergies
Diabetes Drug Sensitivities Heart Disease Lyme Disease Otitis Media
Hepatitis Rheumatic Fever Neuromuscular Disease Strep Infections
Asthma Mononucleosis Chicken Pox Vision Disorder Convulsive
Disorder Hearing Disorder ADHD Congenital Defects
OPERATION/INJURIES (PLEASE SPECIFY)
1. 2. 3. ADDITIONAL COMMENTS:
IMMUNIZATIONS:
Vaccine Type DISEASE DATE
1st Dose Mo/Day/Yr
2nd Dose Mo/Day/Yr
3rd Dose Mo/Day/Yr
4th Dose Mo/Day/Yr
5th Dose Mo/Day/Yr
6th Dose Mo/Day/Yr
DT(a)P/DT/Td OPV MMR Measles MCV PCV Hepatitis B Varicella Flu
HIB Lead Level: Date of Last Lead Test: Mantoux (PPD) Date
Administered Date read and Results: MEDICATIONS: ____________
ALLERGIES: Drug: Environmental: Food: ___________________
BOTH SIDES OF THIS FORM MUST BE COMPLETED
-
TO BE COMPLETED BY FAMILY PHYSICIAN OR PEDIATRICIAN
FRANKLIN TOWNSHIP PUBLIC SCHOOLS Students Name: Exam Date:
Height: Weight: Pulse: B/P: Vision: Uncorrected Right: Left:
Vision: Corrected Right: Left: Hearing Screen: Right: Left: Normal
Exam Abnormal Findings: Head Eyes Ears Nose Throat Lymph Glands
Heart Lungs Abdomen Hernia Genitalia Skin Orthopedic Scoliosis
Neurological Speech Nutrition Any limitation of activity? No Yes
(please explain) Physicians signature: Date: Physicians Name,
Address, and telephone number:
COMPLETE BOTH SIDES MM 11/06
PIC Registration Requirements online versionThe Registration
Process
Registration Formhome language surveyemergency cardParents
consent of records 2011Parent Information Center/Office of Student
RegistrationPARENTS CONSENT FOR TRANSFER OF RECORDSParent
Information Center/Office of Student Registration
residency affidavitNJ Family Care Health
InsuranceIMM-combinedimm-19-memoIMM
nursing services formHealth appraisalFRANKLIN TOWNSHIP PUBLIC
SCHOOLSCHILDREN IN FAMILY
Physical FormSTUDENT HEALTH AND PHYSICAL EXAM
FORMTYPE/YEARDISEASE HISTORYFRANKLIN TOWNSHIP PUBLIC
SCHOOLSCOMPLETE BOTH SIDES
AddressIDirecci6n: CityStateCiudadlEslado: Zip CodeC6digo
Postal: Last Name Apellido_2: First NamelNombre:
ReiationshipIRelaci6n: Address if different from abovelDireccion si
es diferente: CityStatelCiudadlEstado: Zip CodeCodigo Postal: Last
NameApellido: First NamelNombre_2: ReiationshipIRelaci6n_2: Address
if different from aboveIDireccion si es diferente:
CityStateCiudadlEstado: Zip CodeCodigo Postal_2: Last Name
Apellido_3: First NamelNombre_3: SchooVEscuela: Last
NameApellido_2: Last NameApellido_3: High School
StudentslEstudiantes de Escuela Secundaria: If so what is the Name
Cual es el nombre de la escuela: stateestado: que ano: Country 01
Dlrth: Grade: Last Name_2: First Name_2: Middle Name_2: Title:
Address: City: State: Zip Code: Alt Telephone Ext: Birthdate
optional: Employer: Work Address: City_2: State_2: Zip Code_2: Work
Hours From To: 5:00 Email Address: Last Name_3: First Name_3:
Middle Name_3: Title_2: Address_2: City_3: State_3: Zip Code_3: AIL
Telephone Ext: B irthdate optional: Employer_2: Work Address_2:
City_4: State_4: Zip Code_4: Work Telephone Ext_2: Email Address_2:
First Contact: Telephone Ext: Relationship to Student: Address_3:
City_5: State_5: Zip Code_5: Secondary Contact: Telephone Ext_2:
Relationship to Student_2: Address_4: City_6: State_6: Zip code:
Medical Alert 1: Medical Alert 2: Physician: Telephone Ext_3:
Please Complete 1: Please Complete 2: Bus No: Phone number: If
there is a legal separation in the family the school district
requires legal documentation that indicates which of the parents:
Previous Grade: The: 1974: Print Name of ParentGuardian: Grado
Previo: El Distrito Escolar de: DIRECCIN DE ESCUELA PREVIA: PARENTS
CURRENT ADDRESSDIRECCION DEL PADRE: OWNERS CURRENT ADDRESSDIRECCION
ACTUAL DEL DUENO: RELATIONSHIP TO PARENTRELACION AL PADRE: I: the
parent of: hereby affirm that I am residing with: at the following
address: I hereby affirm that: are residing with me at: Name_2:
Relationship: Address_7: Phone: undefined_5: Within NJ: which
school in NJ Out of State: Out of country: Fathers Name:
EmployerPhone: Mothers Name: EmployerPhone_2: Guardian: EMERGENCY
CONTACT PERSON AND NUMBER: FAMILY PHYSICIANCLINIC: LANGUAGE SPOKEN
AT HOME: Allergies: Diabetes: Drug Sensitivities: Heart Disease:
Lyme Disease: Otitis Media: Hepatitis: Rheumatic Fever:
Neuromuscular Disease: Strep Infections: Asthma: Mononucleosis:
Chicken Pox: Vision Disorder: Convulsive Disorder: Hearing
Disorder: ADHD: Congenital Defects: 1_2: 2_3: 3_3: MEDICATIONS 1:
MEDICATIONS 2: Drug: Environmental: Food: Problems: Yes: SpecialEd
No: Hispanic: NativeHawaiian: Asian: AmericanIndian:
BlackOrAfricanAmerican: White: WorkPhone: CellPhone:
EmergencyContactCheckBox: HighSchoolYes: HighSchoolNo:
VocationalYes: VocationalNo: HomePhone: Email: ParentHomePhone:
ParentWorkPhone: ParentCellPhone: ParentEmail: First NamelNombre_4:
Sibling3FirstName: SchooVEscuela_2: Sibling3School:
GenderFemale:
GenderMale:
unte ot tntry m u: SchoolEntryDateUS: Telephone:
AltTelephoneExt: SurveyMother: SurveyFillFather: SurveyFillGrandpt:
SurveyFillGuardian: SurveyFillOther: SurveyBeganEnglish:
SurveyBeganSpanish: SurveyBeganGuj: SurveyBeganOther:
SurveyFillOtherText: SurveyFamEnglish: SurveyFamSpanish:
SurveyFamGuj: SurveyFamOther: SurveyBeganOtherText:
SurveyMomEnglish: SurveyMomSpanish: SurveyMomGuj: SurveyMomOther:
SurveyFamOtherText: SurveyDadEnglish: SurveyDadSpanish:
SurveyDadGuj: SurveyDadOther: SurveyMomOtherText:
SurveyDadOtherText: SurveyChild2momEnglish: SurveyChild2momSpanish:
SurveyChild2momGuj: SurveyChild2momOther: SurveyChild2momOtherText:
SurveyChild2DadEnglish: SurveyChild2DadSpanish: SurveyChild2DadGuj:
SurveyChild2DadOther: SurveyChild2SiblingsEnglish:
SurveyChild2SiblingsSpanish: SurveyChild2SiblingsGuj:
SurveyChild2SiblingsOther: SurveyChild2DadOtherText:
SurveyChild2FriendsEnglish: SurveyChild2FriendsSpanish:
SurveyChild2FriendsGuj: SurveyChild2FriendsOther:
SurveyChild2SiblingsOtherText: SurveyChild2FriendsOtherText: Work
Telephone Ext: Work Hours From: Telephone_2: Telephone_2ext:
SurveyEthnicityWhite: EmerMedInsNo: EmerFamCareYes: EmerFamCareNo:
EmerMedInsYes: EmerCallMe: EmerNoCall: AffLastName2: AffLastName1:
AfffirstName1: AfffirstName2: AffLastName3:
AffLastName4:
AffLastName5:
AffGender1: AffGender2: AffGender3: AffGender4: AffGender5:
AffPhone1: AffPhone2: AffPhone3: AffPhone4: AffPhone5:
AffParentLastName: AffParentFirstName: AffParentWorkPhone:
AffParentCellPhone: AffOwnerFirstName: AffOwnerLastName:
AffOwnerHomePhone: AffOwnerWorkPhone: AffOwnerCellPhone:
AffParentHomePhone: NjiisNo: MedYes: MedNo: NjiisYesspan: NjiisYes:
MedNoSpan: HAFGrade: HAFAge: EmployerPhone_3: HAFEmrPhone:
HAFDRPhone: HAFName2: HAFDOB3: HAFDOB4: HAFName 1: HAFName 3:
HAFName 4: SurveyEthnicityPI: SurveyEthnicityLat:
SurveyEthnicityAsian: SurveyEthnicityBlack: SurveyEthnicityAI:
LegalSeparationCheckBox: PreviousSchoolName1: PreviousSchoolName2:
PreviousSchLoc1: PreviousSchLoc2: PreviousGrComp1: PreviousGrComp2:
PreviousSchDate1: PreviousSchDate2:
PreviousSchoolLangofInstruction1: PreviousSchoolLangofInstruction2:
Text4: Last NameStudent:
MiddleNameStudent:
First NameStudent:
DateOfBirthStudent:
HAFDOB1: HAFDOB2: BirthPlace:
Address_5:
PhoneEXT: EmrWorkExt: WExt1: Work IloLlrsTo: Work IloLlrs From:
Emerbuswalker:
