School: zz REGISTRATION CHECKLIST€¦ · SHARED RESIDENCY AFFIDAVIT . Shared housing is defined as two or more families living at one address; a parent (student’s family) and a

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OFFICE USE ONLY

School:

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REGISTRATION CHECKLIST PLEASE BRING ORIGINAL DOCUMENTS ONLY NOT PHOTOCOPIES

1. REQUIRED DOCUMENTS AND FORMS Registration Form (ONLY A PARENT OR LEGAL GUARDIAN CAN REGISTER A STUDENT)

Student Proof of Age: Certified transcript of Birth or Baptismal Certificate; If not available then Passport; If neither of the first two

options are available, then the District will consider other documentation if you’ve had them for two years, including but not limited to 1. Official driver’s license; 2. State or other government issued identification;

3. School photo identification with date of birth; 4. Consulate identification card; 5. Military dependent identification card

6. Documents issued by Federal State or local agencies (e.g. local social service agency, Federal Office of Refugee Resettlement) 7. Court orders or other court-issued documents; 8. Native American tribal document; or

9. Records from non-profit international aid agencies and voluntary agencies.

Parent/Legal Guardian’s Photo Identification (Including but not limited to: Valid driver’s license/I.D. card, Military I.D., Other Government Issued

photo I.D.) and proof indicating either: 1. That they are the parent(s) with whom the child lawfully resides; or 2. That they are the person(s) in parental relation to the child, over whom they have total and permanent custody and control, and

describing how they obtained total and permanent custody and control, whether through guardianship or otherwise. Guardianship Affidavit DSS 2999 Form (If Applicable) Free and Reduced Lunch Form (if applicable)

Home Language Questionnaire Residency Questionnaire - Mc Kinney Vento Act Form Photograph and Video Consent to Release Form

Transportation Request Form

Release of Student Records Form Student School Records

Student Emergency Form Health Exam Form Immunization record Dental Health Certificate

FOR PUPIL PERSONNEL (PPS) ONLY Medicaid Consent

Individualized Education Program (IEP)/504 Plan

District of Location (DOL) - District in which private school is located or

District of Residence (DOR) - District in which student maintains a permanent residence requires the following additional documents: Current enrollment record on school letterhead

Individualized Education Program (IEP)/504 plan

FOR NON-PUBLIC SCHOOLS TRANSPORTATION ONLY

Registration Form Transportation Form for Non-Public School

Parent/Legal Guardian Photo ID Student Proof of Age (See Above) Proof of Residency (See below)

2. PROOF OF RESIDENCY AND OCCUPANCY OWNERS Proof of ownership of a house or condominium, such as a deed or mortgage statement AND two utility bills showing your

name and address as listed in deed or mortgage statement, OR at least two other proofs of residency. RENTERS Current residential lease AND two utility bills showing your name and the address listed on the lease, OR at least two other

proofs of residency. LIVING WITH If you are living with relatives/friends or rent a room and do no hold a lease: A statement or affidavit by a third-party landlord,

owner or tenant from whom the parent(s) or person(s) in parental relation leases or with whom they share property within the district OR a statement or affidavit by a third party relating to the parent(s)' or person(s) in parental relation's physical presence in the district AND two utility bills showing your name, OR at least two other proofs of residency.

The District will consider other residency documentation, including but not limited to: rent receipt; current pay stub; income tax form or statement (e.g., W2); bank statement; canceled check; utility or other bills (including insurance bill); membership documents (e.g., library cards) based upon residency; voter registration

document(s); official driver's license, learner's permit or non-driver identification; State or other government issued identification; documents issued by Federal, State or local agencies (e.g., local social service agency, Federal Office of Refugee Resettlement); or evidence of custody of the child, including but not limited to judicial custody

orders or guardianship papers.

STUDENT ID:

REGISTRATION DATE:

New Student Re-Entry

REGISTRATION FORM 1. STUDENT INFORMATION Full Name (As shown on Birth Certificate) Date of Birth (MM/DD/YYYY) Male

Female

Home Address

Single Home Apartment Duplex Condominium Co-op

Registering for:

The Early Childhood Program (Pre-K) Lee F. Jackson Elementary School (K-1) Highview Elementary School (2-3) Richard J. Bailey Elementary School (4-6) Woodlands Middle/High School (7-12) Transportation Services for Non-Public Schools Committee on Preschool Special Education (CPSE) District of Location (DOL) District of Residence (DOR)

Race

American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White

Previous School Attended Grade registering for:

Is student Hispanic/Latino?

Yes No

2. PARENT/LEGAL GUARDIAN INFORMATION Full Name Full Name

Relationship

Mother Father Other:

Relationship

Mother Father Other:

Priority 1 Home Mobile Work ( )


Priority 2 Home Mobile Work ( ) Priority 2 Home Mobile Work ( )


Email Email

Home Address (If you do not reside with student please complete) Same as student

Home Address (If you do not reside with student please complete) Same as student

3. SIBLINGS LIVING AT HOME (CENSUS) Full Name Relationship Date of Birth School Attending Grade

Full Name Relationship Date of Birth School Attending Grade




I understand that I am being asked to provide information that will allow the Greenburgh Central School District to verify that my child is legally entitled to an education in the District and understand that the District is educating only those children who have a right to that education by living within the district. The law assumes that a child resides with their parent or legal guardian. If the claim is made that a child’s residence is with someone other than the child’s parent or legal guardian, it will be necessary to obtain additional information to establish that child's residency in our district. Falsification of information will be grounds for invalidating the student’s enrollment, and possible legal action to collect tuition charges.

Signature of Parent/Legal Guardian Date

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475 West Hartsdale Avenue, Hartsdale, NY 10530 | 914.761.6000 | www.greenburghcsd.org

GUARDIANSHIP AFFIDAVIT IF A SINGLE PARENT, LEGAL GUARDIAN, FOSTER PARENT OR FOSTER CARE AGENCY

Student’s Full Legal Name

1. SINGLE PARENT Legal Custody of Child is with Mother Father Is there a Joint custody agreement? Yes No List any restrictions other parent has regarding child List type and date of legal document provided, if any

2. LEGAL GUARDIAN Name of child’s natural parent(s)

Address or whereabouts of natural parent(s) List any official documents, if any, indicating custody and restrictions

3. FOSTER PARENT OR FOSTER CARE AGENCY All foster parents must present at the time of registration of a foster child, a placement letter from the agency, on their letterhead indicating the foster parent’s name plus date of birth and grade of each student to be registered. Agency must also include health history and dates of mandatory immunizations of each student, and a DSS 2999 form with CIN/Medicaid number, ACS or SOO number for each student. Name of Foster Parent(s)

Name of Agency Type of Agency Agency Code Number

Agency Address Case Worker or Social Worker Telephone

DSS Case Number CB Number CIN Number

Date child was placed at current location Date at previous location

In executing this affidavit, I acknowledge that the Greenburgh Central School District attempts to maintain current family information to help ensure student safety, proper communication with parents, and appropriate educational programming. Parents who are divorced, legally separated, or otherwise live apart should supply the District with relevant information and documentation, including custody orders, regarding who is responsible for the custody and care of their child, and who is permitted to make educational decisions for that child. A non-custodial parent's participation in his or her child's education will be governed by the terms of any custody order. I understand that if the information provided in connection with this Affidavit is determined to be false or misleading, resulting in the child/children named above not to be legally entitled to attendance in the Greenburgh Central School District, the School District will take legal action to recoup valid tuition charges and legal fees. The Student’s residence within the School District has not been established solely to attend the schools thereof. The foregoing facts are sworn to induce the School District to enroll the student in the schools of the District. I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.

I HEREBY SWEAR THAT THE ANSWERS TO THE FOREGOING QUESTIONS ARE TRUE AND CORRECT AND I UNDERSTAND THAT I MAY BE SUBJECT TO CRIMINAL PROSECUTION FOR PERJURY IF I HAVE KNOWINGLY ANSWERED ANY OF THE QUESTIONS FALSELY.

Parent/Legal Guardian Signature Date STATE OF NEW YORK COUNTY OF WESTCHESTER

I do hereby certify that on the ____ day of __________________, 20____,

Did state on oath that the answers to the questions on the foregoing document were true and correct to the knowledge of the affiant. Notary Public

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475 West Hartsdale Avenue, Hartsdale, NY 10530 | 914.761.6000 | www.greenburghcsd.org

SHARED RESIDENCY AFFIDAVIT Shared housing is defined as two or more families living at one address; a parent (student’s family) and a primary resident. When two families live in shared housing, both parties must complete a Shared Residency Statement/Affidavit for the student to register. PRIMARY residents will be requested to supply all proofs of Residency and Occupancy Documents before a final residency decision can be made, and must be provided within three business days of the request for enrollment and PARENTS AND LEGAL GUARDIANS will need all proofs of Residency and Occupancy documents. A residence is defined by where a student lives 7 days a week; or over 50% of the time if sharing split custody. Only one address may be used. A business address or an address used for child care purposes, either through a relative or private provider, may not be used as a child’s residential address, and will be grounds for exclusion from the District’s schools for lack of residency. Falsification of information given to prove residency will also be grounds for exclusion from the District’s schools for lack of residency, and possible legal action to collect tuition charges.

1. TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN Student Full Legal Name Date of Birth Grade Gender

Male Female

Student Full Legal Name Date of Birth Grade Gender

Male Female

Parent/Legal Guardian Name 1 Parent/Legal Guardian Name 2

Address Address

Telephone Telephone

This living arrangement is Permanent Temporary; Duration:

This address listed above is my only residence, and I agree to notify the Greenburgh Central School District if there is any change in the status of residence. I understand that home visitation and residency verification may be part of the process when a Shared Residency Statement/Affidavit establishes residency.

PARENT/LEGAL COURT APPOINTED GUARDIAN DRIVER’S LICENSE/ID CARD NUMBER DATE

2. TO BE COMPLETED BY HOMEOWNER Name (Owner, Lease Holder, Qualified Relative, Friend, Neighbor, etc.) I declare that I am the owner of the property at the following address

Telephone

IT IS NOT REQUIRED THAT THE STATEMENT BE MADE UNDER OATH; HOWEVER, THE DISTRICT MAY GIVE MORE WEIGHT TO AFFIDAVITS AS OPPOSED TO STATEMENTS. I make this affidavit to induce Greenburgh Central School District to allow the children named above to enroll in or to continue to attend school in the District. I acknowledge that if they do not live at this address or any address within the District, that they will not be allowed to continue attendance in the District. I further acknowledge that falsification of information will be grounds for invalidating the student’s enrollment, and possible legal action to collect tuition charges. I understand that in the event this family relocates and is no longer living at the address as mentioned above, I should notify the Greenburgh Central School District immediately of said move. I understand that statements made in this affidavit will be relied upon by the Greenburgh Central School District. I swear/affirm that these statements are true under the penalties of perjury, and I understand that the filing of a false instrument and the theft of services from a governmental agency such as a school district may be crimes punishable under New York State Law.

Landlord Signature Date Pursuant to Section 3202 of the Education Law STATE OF NEW YORK COUNTY OF WESTCHESTER

I do hereby certify that on the ____ day of __________________, 20____,

Did state on oath that the answers to the questions on the foregoing document were true and correct to the knowledge of the affiant.

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Date Withdrew__________ F ____R _____D_____

2019-2020 Application for Free and Reduced Price School Meals/Milk

To apply for free and reduced price meals for your children, read the instructions on the back, complete only one form for your household, sign your name and return it to the address listed below. Call (phone number), if you need help. Additional names may be listed on a separate paper.

Return Completed Applications to: (School Name) (Street Name) (City, State , Zip Code)

1. List all children in your household who attend school:

Student Name School Grade/Teacher

Foster Child

Homeless Migrant, Runaway

2. SNAP/TANF/FDPIR Benefits: If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 4, and sign the application. Name: ______________________________________ CASE #: __________________________________

3. Report all income for ALL Household Members (Skip this step if you answered ‘yes’ to step 2) All Household Members (including yourself and all children that have income). List all Household members not listed in Step 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any other source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Name of household member Earnings from work before deductions Amount / How Often

Child Support, Alimony Amount / How Often

Pensions, Retirement Payments Amount / How Often

Other Income, Social Security Amount / How Often

No Income

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

$ ________ / ________ $ ________ / ________ $ ________ / ________ $ ________ / ________

Total Household Members (Children and Adults)

*Last Four Digits of Social Security Number: XXX-XX- __ __ __ __

*When completing section 3, an adult household member must provide the last four digits of their Social Security Number (SS#), or mark the “I do not have a SS# box” before the application can be approved.

4. Signature: An adult household member must sign this application before it can be approved. I certify (promise) that all the information on this application is true and that all income is reported. I understand that the information is being given so the school will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and federal laws, and my children may lose meal benefits. Signature: ___________________________________________________ Date: ___________________ Email Address: ________________________________________________ Home Phone: _____________________ Work Phone: _________________________ Home Address:____________________________________________

5. Ethnicity and Race are optional; responding to this section does not affect your children’s eligibility for free or reduced price meals.

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race (Check one or more) : American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Island White

DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLY Annual Income Conversion (Only convert when multiple income frequencies are reported on application)

Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X 24; Monthly X 12

SNAP/TANF/Foster Income Household: Total Household Income/How Often: _________________/________________ Household Size: _________________ Free Meals Reduced Price Meals Denied/Paid Signature of Reviewing Official________________________________________________________ Date Notice Sent:________________

I do not have a SS#

APPLICATION INSTRUCTIONS

To apply for free and reduced price meals, complete only one application for your household using the instructions below. Sign the application and return the application to _____________________. If you have a foster child in your household, you may include them on your application. A separate application is not needed. Call the school if you need help: ____________________. Ensure that all information is provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application.

PART 1 ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE APPLICATION FOR YOUR HOUSEHOLD. (1) Print the names of the children, including foster children, for whom you are applying on one application. (2) List their grade and school. (3) Check the box to indicate a foster child living in your household, or if you believe any child meets the description for homeless, migrant, runaway (a school staff will confirm this eligibility). PART 2 HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 4. (1) List a current SNAP, TANF or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in your household. The case number is provided on your benefit letter. (2) An adult household member must sign the application in PART 4. SKIP PART 3. Do not list names of household members or income if you list a SNAP case number, TANF or FDPIR number. PART 3 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 4. (1) Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are applying for, all other children,

your spouse, grandparents, and other related and unrelated people in your household. Use another piece of paper if you need more space. (2) Write the amount of current income each household member receives, before taxes or anything else is taken out, and indicate where it came from,

such as earnings, welfare, pensions and other income. If the current income was more or less than usual, write that person’s usual income. Specify how often this income amount is received: weekly, every other week (bi-weekly), 2 x per month, monthly. If no income, check the box. The value of any child care provided or arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income for this program.

(3) Enter the total number of household members in the box provided. This number should include all adults and children in the household and should reflect the members listed in PART 1 and PART 3.

(4) The application must include the last four digits only of the social security number of the adult who signs PART 4 if Part 3 is completed. If the adult does not have a social security number, check the box. If you listed a SNAP, TANF or FDPIR number, a social security number is not needed.

(5) An adult household member must sign the application in PART 4. OTHER BENEFITS: Your child may be eligible for benefits such as Medicaid or Children’s Health Insurance Program (CHIP). To determine if your child is eligible, program officials need information from your free and reduced price meal application. Your written consent is required before any information may be released. Please refer to the attached parent Disclosure Letter and Consent Statement for information about other benefits.

USE OF INFORMATION STATEMENT Use of Information Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not submit all needed information, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the primary wage earner or other adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We may share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

DISCRIMINATION COMPLAINTS

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or (3) email: [email protected].

http://www.ocio.usda.gov/sites/default/files/docs/2012/Complain_combined_6_8_12.pdf

http://www.ascr.usda.gov/complaint_filing_cust.html

1 ENGLISH

Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.

STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12

Lissette Colón-Collins, Assistant Commissioner

Office of Bilingual Education and World Languages

55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB

Brooklyn, New York 11217 Albany, New York 12234

Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948

Home Language Questionnaire (HLQ)

H O M E L A N G U A G E C O D E

Language Background (Please check all that apply.)

1. What language(s) is(are) spoken in the student’s homeor residence?

English Other

specify

2. What was the first language your child learned? English Other

_________________________________________ specify

3. What is the Home Language of each parent/guardian? Mother Fatherspecify specify

Guardian(s)specify

4. What language(s) does your child understand? English Other

specify

5. What language(s) does your child speak? English Other Does not speak

specify

6. What language(s) does your child read? English Other Does not read

specify

7. What language(s) does your child write? English Other Does not write

specify

TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::

Please write clearly when completing this section. S T U D E N T N A M E :

First Middle Last

D A T E O F B I R T H : G E N D E R :

Male Female Month Day Year

P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :

Last Name First Name Relation to Student

S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T

I N F O R M A T I O N S Y S T E M :

District Name (Number) & School Address

2 ENGLISH

Home Language Questionnaire (HLQ)—Page Two

Relationship to student: Mother Father Other:

Educational History

8. Indicate the total number of years that your child has been enrolled in school _____________

9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write inEnglish or any other language? If yes, please describe them.

Yes* No Not sure *If yes, please explain:____________________________________________________________________________

How severe do you think these difficulties are? Minor Somewhat severe Very severe

10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below

10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .

Age at which services received (Please check all that apply):

Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)

10c. Does your child have an Individualized Education Program (IEP)? No Yes

11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

12. In what language(s) would you like to receive information from the school? _________________________________________________

Month: Day: Year:

Signature of Parent or of Person in Parental Relation Date

OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ

NAME: POSITION:

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:

NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW

NAME: POSITION:

ORAL INTERVIEW NECESSARY: NO YES

**DATE OF INDIVIDUAL INTERVIEW:

OUTCOME OF

INDIVIDUAL

INTERVIEW:

ADMINISTER NYSITELL

ENGLISH PROFICIENT

REFER TO LANGUAGE PROFICIENCY TEAMMO DAY YR.

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL

NAME: POSITION:

DATE OF NYSITELLADMINISTRATION:

PROFICIENCY LEVEL

ACHIEVED ON

NYSITELL: ENTERING EMERGING TRANSITIONING EXPANDING COMMANDING

MO. DAY YR.

FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:

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Administration Building | 475 West Hartsdale Avenue, Hartsdale, NY 10530 | www.greenburghcsd.org

RESIDENCY QUESTIONNAIRE STUDENT INFORMATION School/Local Educational Agency

GREENBURGH CENTRAL SCHOOL DISTRICT Full Name (First, Middle, Last) Male Female

Address Date of Birth

Telephone

Student ID Grade

The answer you give below will help the District determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents

normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

Is your current address a temporary living arrangement? Yes No

If so, is this temporary living arrangement due to the loss of housing or economic hardship? Yes No If you answered YES please complete the remainder of this form. If NO, please stop here and sign the bottom of this form.

Where is the student currently living? (Please check one box) In a shelter With another family or other person because of loss of housing or as a result of economic hardship (sometimes called “doubled-up”)

In a hotel/motel In a car, park, bus, train, or campsite Other temporary living situation (Please describe):

In permanent housing

Print Name of Parent/Legal Guardian, or Student (for unaccompanied homeless youth)

Signature Date

NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a Designation Form is completed. If ANY box other than “In Permanent Housing” is checked, then the student/family should be immediately referred to the MV Liaison. In such cases, proof

of residency and other documents usually needed for enrollment are not required and the student is to be immediately enrolled.

After the student has been enrolled, the district/school must contact the previous district/school attended to request the student's educational

records, including immunization records, and the enrolling district's LEA liaison must help the student get any other necessary documents or immunizations.


PHOTOGRAPH AND VIDEO CONSENT TO RELEASE FORM

INFORMATION Unless objection to any of the following specific items of information is submitted in writing by parents or legal guardians or by those students themselves who are over the age of 18 years, the Greenburgh Central School District herewith gives notice of intention to provide, release or publish in newsletters, video, websites, school or student newspapers, magazines, yearbooks, daily or weekly newspapers, athletic programs, news releases, or other publications any or all of the following information pertaining to students as may be appropriate under the circumstances: name of student, photos of student, names of parents, address, telephone number, date and place of birth, participation in school activities or sports, weight and height if a member of an athletic team, dates of attendance, degrees, and awards received, and most recent educational institution attended.

Parents and eligible students have a right to opt out of the inclusion of information about the student as directory information, photo/image, and student work under FERPA.

ABOUT FERPA The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.

FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are "eligible students."

Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies.

Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.

Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31):

School officials with legitimate educational interest Other schools to which a student is transferring Specified officials for audit or evaluation purposes Appropriate parties in connection with financial aid to a student Organizations conducting certain studies for or on behalf of the school

Accrediting organizations To comply with a judicial order or lawfully issued subpoena Appropriate officials in cases of health and safety emergencies State and local authorities, within a juvenile justice system,

pursuant to specific State law.

CONSENT Parents who do not desire release of any of the above directory information must make a specific request in writing to the Superintendent of Schools by the last day of September each school year. Failure to make such a request shall be deemed consent to release, provide or publish the directory/photo information.

Yes, I give my consent to the Greenburgh Central School District to use photo or video images taken of my child in school brochures, advertisements for the school, the District website, in social media, and in other school publications as they see fit. I agree to hold harmless from any liability which may result from the use of said photograph(s) or images.

No, I do not give my consent to the Greenburgh Central School District to use pictures taken of my child in school brochures, advertisements for the school, on the website, in social media, and other school publications as they see fit.

Student’s Full Name Male Female

Grade

Parent/Legal Guardian Signature Date


Frank Gunn Director of Transportation

T: 914.761.6000 ext. 3140 E: [email protected]

________________

Dr. Tahira A. DuPree Chase Superintendent of Schools

TRANSPORTATION FORM 1. ARE YOU REQUESTING TRANSPORTATION?

Yes - If yes, please complete form No – If no, please initial______________ Mileage Requirements: .5 to 15 miles

2. STUDENT INFORMATION Full Name (First, Middle, Last)

Home Address Student will be attending: The Early Childhood Program Lee F. Jackson Highview Richard J. Bailey Woodlands Middle/High School

3. PARENT/LEGAL GUARDIAN INFORMATION Full Name (First, Middle, Last)

Email

Home Telephone Work Telephone Mobile

4. PRE-K TO 4TH GRADE ONLY - Individuals Permitted to Receive Student Greenburgh Central School District policy requires, Pre-K through fourth-grade students to be met by a parent/legal guardian at the bus stop. Please use this form to indicate who is authorized to receive your child at the bus stop, other than you. Our policy also states that a parent or guardian may opt out of this procedure by notifying the school and the Transportation Department in writing at the beginning of the school year or with 30 days advance written notice. This form must be filled out and returned to the Transportation Department before the first day of school. Please list all adults who will be permitted to take your child off the bus. Students will not be released to anyone not listed on this form. (Identification is required) If there is no one from this list present at the time of drop off, students will remain on the bus and returned to the appropriate school after the remainder of the bus route is completed. Please Note: It may take up to two days to have routing completed. Also, if needing Daycare Transportation, you must fill out the daycare form at the Transportation Office.

FULL NAME RELATIONSHIP TELEPHONE

PARENT/LEGAL GUARDIAN SIGNATURE DATE

zz


RELEASE OF STUDENT RECORDS 1. STUDENT INFORMATION The following student has registered with the Greenburgh Central School District. Please accept this document as formal approval for the release of all official records including but not restricted to transcripts, testing information, special education, health, and immunization records, academic, attendance, disciplinary records, individual evaluations, IEP’s, Section 504 Accommodation Plans, and a final transcript if

high school student.

Date Date of Birth Grade

Student Full Name

School & District transferring from School Contact if Known

Previous School Address Telephone Fax

Email

Student will be attending

The Early Childhood Program District of Location District of Residence Lee F. Jackson Elementary School Elmwood Day School (K-1)

Highview Elementary School Maria Regina High School

Richard J. Bailey Elementary School Mohawk County Day School (K-1) Woodlands Middle/High School Sacred Heart School

Solomon Schechter Upper School

2. AUTHORIZATION BY PARENT/LEGAL GUARDIAN The Family Educational Rights and Privacy Act (“FERPA”) and the Individuals with Disabilities Education Improvement Act (“IDEA”) require schools and providers to have written consent from a parent or legal guardian before they can release student records or communicate about the student. In the case of students eighteen (18) years old or older, written permission of the eligible student must be obtained. In accordance with FERPA and the IDEA, I hereby authorize Greenburgh Central School District to obtain my child’s educational records

(including academic, health, attendance, disciplinary, individual evaluations, IEP’s, section 504 accommodation plans, and a final transcript if high school student.)

Parent/Legal Guardian Signature Date

School Administrator Signature Date

OFFICE USE ONLY Requested by

District Registrar

Early Childhood Program

Pupil Personnel Services (Special Education/504) Other:

Fax

914.761.7022 (District Registrar)

914.949.1548 (Early Childhood Program) 914.761.2369 (Pupil Personnel Services)

Other:

Page 1 of 2

STUDENT EMERGENCY CARD

1. STUDENT INFORMATION Full Name Date of Birth (MM/DD/YYYY) Male

Female School

The Early Childhood Program (Pre-K) Lee F. Jackson Elementary School (K-1) Highview Elementary School (2-3) Richard J. Bailey School (4-6) Woodlands Middle/High School (7-12)

Address

2. PARENT/LEGAL GUARDIAN INFORMATION Full Name Full Name

Relationship

Mother Father Other: Relationship

Mother Father Other: Home Address (If you do not reside with student please complete). Same as student

Home Address (If you do not reside with student please complete). Same as student





Email: Email:

3. EMERGENCY CONTACTS (CONTACTS LISTED BELOW WILL ALSO BE AUTHORIZED TO PICK UP CHILD WITH VALID PHOTO ID)

CONTACT 1 CONTACT 2

Relationship: Relationship:





Address Address

CONTACT 3 CONTACT 4

Relationship: Relationship:





Address Address

School Year ________________

Student ID _________________

Bus Number: AM: ____ PM: ____

Teacher __________________

Room Number_____ Grade ____

Page 2 of 2

4. SIBLINGS ATTENDING GREENBURGH SCHOOLS Full Name Relationship Date of Birth School Attending

Full Name Relationship Date of Birth School Attending




5. HEALTH INFORMATION Name of Physician/Clinic Telephone

Health Insurance Health Insurance Number

Address

Hospital child should be taken to if Parent or Doctor cannot be reached

St. John’s Riverside Hospital – Dobbs Ferry Pavilion Westchester Medical Center White Plains Hospital

Allergies/Medications/Special Health Considerations

6. EMERGENCY DISMISSAL In the event of unexpected early dismissal days, severe storms or other unscheduled emergencies, my child is to:

Walk Home Ride the school bus as usual (If bus service is available) Ride the bus to babysitter/Day Care. Bus Number: _______ Picked up by Parent Picked up by the following emergency contact ___________________________________________________ Other arrangements:

Parent/Legal Guardian Signature: Date

Rev. 5/4/2018 Page 1 of 2

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR

Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or

Committee on Pre-School Special education (CPSE).

STUDENT INFORMATION

Name: Sex: M F DOB:

School: Grade: Exam Date:

HEALTH HISTORY

Allergies ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached

☐ Food ☐ Insects ☐ Latex ☐ Medication ☐ Environmental

Asthma ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Asthma Care Plan Attached

☐ Intermittent ☐ Persistent ☐ Other : ___________________________

Seizures ☐ No ☐ Medication/Treatment Order Attached ☐ Seizure Care Plan Attached

☐ Yes, indicate type ☐ Type: __________________________ Date of last seizure: ______________

Diabetes ☐ No ☐ Medication/Treatment Order Attached ☐ Diabetes Medical Mgmt. Plan Attached

☐ Yes, indicate type ☐Type 1 ☐ Type 2 ☐ HbA1c results: ____________ Date Drawn: _____________Risk Factors for Diabetes or Pre-Diabetes:

Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.

Hyperlipidemia: ☐ No ☐ Yes Hypertension: ☐ No ☐ Yes

PHYSICAL EXAMINATION/ASSESSMENT

Height: Weight: BP: Pulse: Respirations:

TESTS Positive Negative Date Other Pertinent Medical Concerns

PPD/ PRN ☐ ☐ One Functioning: ☐ Eye ☐ Kidney ☐ Testicle

Sickle Cell Screen/PRN ☐ ☐ ☐ Concussion – Last Occurrence: __________________________

Lead Level Required Grades Pre- K & K Date ☐ Mental Health: ________________________________

☐ Other: ☐ Test Done ☐ Lead Elevated > 10 µg/dL

☐ System Review and Exam Entirely Normal

Check Any Assessment Boxes Outside Normal Limits And Note Below Under Abnormalities

☐ HEENT ☐ Lymph nodes ☐ Abdomen ☐ Extremities ☐ Speech

☐ Dental ☐ Cardiovascular ☐ Back/Spine ☐ Skin ☐ Social Emotional

☐ Neck ☐ Lungs ☐ Genitourinary ☐ Neurological ☐ Musculoskeletal

☐ Assessment/Abnormalities Noted/Recommendations: Diagnoses/Problems (list) ICD-10 Code

_________________________ _____________

_________________________ _____________

_________________________ _____________

☐ Additional Information Attached _________________________ _____________

Rev. 5/4/2018 Page 2 of 2

Name: DOB:

SCREENINGS

Vision Right Left Referral Notes

Distance Acuity 20/ 20/ ☐ Yes ☐ No

Distance Acuity With Lenses 20/ 20/

Vision – Near Vision 20/ 20/

Vision – Color ☐ Pass ☐ Fail

Hearing Right dB Left dB Referral

Pure Tone Screening ☐ Yes ☐ No

Scoliosis Required for boys grade 9 Negative Positive Referral

And girls grades 5 & 7 ☐ ☐ ☐ Yes ☐ No

Deviation Degree: Trunk Rotation Angle:

Recommendations:

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

☐ Full Activity without restrictions including Physical Education and Athletics.

☐ Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications

☐ No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling

☐ No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, Skiing, swimming and diving, tennis, and track & field

☐ Other Restrictions:

☐ Developmental Stage for Athletic Placement Process ONLY

Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports

Student is at Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V

☐ Accommodations: Use additional space below to explain

☐ Brace*/Orthotic ☐ Colostomy Appliance* ☐ Hearing Aids

☐ Insulin Pump/Insulin Sensor* ☐ Medical/Prosthetic Device* ☐ Pacemaker/Defibrillator*

☐ Protective Equipment ☐ Sport Safety Goggles ☐ Other: *Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.

Explain: _____________________________________________________________________________

MEDICATIONS

☐ Order Form for Medication(s) Needed at School attached

List medications taken at home:

IMMUNIZATIONS

☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No

HEALTH CARE PROVIDER

Medical Provider Signature: Date:

Provider Name: (please print) Stamp:

Provider Address:

Phone:

Fax:

Please Return This Form To Your Child’s School When Entirely Completed.


1. STUDENT INFORMATION Please complete this section and take the form to your registered dentist/dental hygienist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist/dental hygienist to fill out Section 2. Return the completed form to the school nurse. Full Name Male Female Birth Date: Grade Will this be your child’s first oral health assessment? Yes No

Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No

School: The Early Childhood Program Lee F. Jackson Elementary School Highview Elementary School Richard J. Bailey Elementary School Woodlands Middle/High School Other:

I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health.

I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below. Parent/Legal Guardian Signature Date

2. TO BE COMPLETED BY THE DENTIST/DENTAL HYGIENIST I. The dental health condition of ______________________________________ on______________ (date of assessment) The date of the assessment needs to be within 12 months of the start of the school year in which it is requested. Check one:

Yes, the student listed above is in fit condition of dental health to permit his/her attendance at the public schools. No, the student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.

NOTE: Not in fit condition of dental health means, that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school. Dentist’s/ Dental Hygienist’s Name

Address (Please print or stamp)

Telephone Dentist’s/Dental Hygienist’s Signature

Optional Sections - If you agree to release this information to your child’s school, please initial here.

II. Oral Health Status (check all that apply). Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a

tooth that is missing because it was extracted as a result of caries OR an open cavity]. Yes No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-

brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].

Yes No Dental Sealants Present

Other problems (Specify):_______________________________________________________________________________

II. Treatment Needs (check all that apply) No obvious problem. Routine dental care is recommended. Visit your dentist regularly. May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation. Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

DENTAL HEALTH CERTIFICATE

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Registration T: 914.761.6000 ext. 3120

F: 914.761.8854

E: [email protected]

________________

Dr. Tahira A. DuPree Chase Superintendent of Schools

MEDICAID CONSENT FORM 1. INFORMATION You are receiving this written notification to give you information about your rights and protections under the Federal Individuals with Disabilities

Education Act (IDEA), so that you can make an informed decision about whether you should give your written consent to allow the Greenburgh

Central School District to use your or your child’s public benefits or insurance to pay for special education and related services that your school

district is required to provide at no cost to you and your child under IDEA.

Funds from a public benefits or insurance program (for example, Medicaid funds) may be used by the Greenburgh Central School District (or, for

preschool students, the county) to help pay for special education and related services, but only if you choose to provide your consent, as explained

below.

Before the Greenburgh Central School District or county can ask you to provide consent to check with the New York State Department of Health

whether your child has public benefits or insurance (e.g., Medicaid coverage and/or a Client Identification Number (CIN)), and to access these

benefits or insurance for the first time, it must provide you with this notification of the rights and protections available to you under IDEA. This

notification is intended to help you understand these rights and protections, including the type of consent your school district will ask you to

provide. Whether or not you provide consent, the Greenburgh Central School District has a continuing responsibility to ensure that your child is

provided all required special education and related services under IDEA at no charge to you or your child.

2. PERMISSION I have received a written notification from the school district that explains my federal rights regarding the use of public benefits or insurance to pay

for certain special education and related services. I understand and agree that the school district may access Medicaid to pay for special education

and related services provided to my child. I understand that:

Providing consent will not impact my child’s/my Medicaid coverage;

Upon request, I may review copies of records disclosed pursuant to this authorization;

Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid;

I have the right to withdraw consent at any time; and

The school district must provide me annual written notification of my rights regarding this consent.

I also give my consent for the school district to release the following records/information about my child to the State’s Medicaid Agency for the

purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared:

Individualized Education Program (IEP)

Written Order/ Referral

Evaluation Reports

Session Notes

Medication Administration

Special Transportation Log

Other Personally Indefinable Information

Other specific records pertaining to Student Services

I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special

education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the

required services in my child’s IEP will be provided to my child at no cost to me.

Student Full Name

Parent/Legal Guardian Full Name

Signature Date