STUDENT ENROLLMENT CHECKLIST

Dear Parent/Guardian: Re:_______________________________

Proof of Residency (two required): Mortgage Statement, Deed, Tax Bill, or Lease Agreement (Upload copies into Family Connection and bring the original documents to your in-school registration appointment) See page 2 “Additional Acceptable Proofs of Residency and Student Age”

Parent/Guardian Identification (one required): Valid Driver’s License, Non-Driver’s ID Card, Passport, or other photo identification (Upload copies into Family Connection and bring the original documents to your in-school registration appointment)

Proof of Student(s) Age (one required): Birth Certificate, Record of Baptism, or Passport (Upload copies into Family Connection and bring the original documents to your in-school registration appointment) See page 2 “Additional Acceptable Proofs of Residency and Student Age”

Copy of Health Exam Forms (Upload copies into Family Connection and bring the original documents to your in-school registration appointment) Copy of Immunization Records (Upload copies into Family Connection and bring the original documents to your in-school registration appointment)

Previous School Information (e.g. report cards, transcripts, IEP, etc.)

Enrollment Form, New Student Registration Form, and Home Language Questionnaire Affidavits (if applicable) (You will not upload Affidavits into Family Connection, but you will bring them bring to your in-school registration appointment)

Other (if applicable): Custody Papers, Legal Documentation (You will not upload other important documents into Family Connection, but you will bring them to your in-school registration appointment)

For School Use Only:

Determine enrollment eligibility OR give 3 days to provide missing information

McKinney-Vento determination – STAC202 Completed

_____ ENL

_____ SPED

_____ Only if paper registration submitted: _____ Enrollment Form _____ New Student Registration Form _____ Home Language QNR

Application complete and accepted

Application incomplete or; Determination that student is/ is not eligible to enroll

Initial determination letter Investigation Complete: Resident Non-resident

_____ Male/Female ______ Grade ______ Assigned Teacher ______ Speech

1

Additional Acceptable Proofs of

Residency and Student Age

Additional Acceptable Proofs of Residency: The District may consider the following documentation and/or information as acceptable proofs of residency, if a mortgage statement, deed, tax bill, or lease agreement is not available. These include but are not limited to:

Pay stub

Income tax form

Utility or other bills

Membership documents (such as library card) based on residency

Voter registration document

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 (such as a social service agency or the federal office of refugee resettlement)

Evidence of custody of the child, including judicial custody orders or guardianship papers

Additional Acceptable Proof of Student(s) Age: The District may consider the following documentation and/or information as acceptable proof of a student’s age if a birth certificate, record of Baptism or passport is not available. These include but are not limited to:

• Official driver’s license • State or other government issued identification • School photo identification with date of birth • Consulate identification card • Hospital or health records • Military dependent identification card • Documents issued by federal, state of local agencies • Court orders or court- issued documents • Native American tribal document • Records from non-profit international aid agencies and voluntary agencies.

Revised 07/09/20 2

55 Kings Highway

Amherst, NY 14226

Phone (716) 362-3000

Fax (716) 836-2537

Amherst Central School District

Disability Education Needs

Has the child ever been reviewed by a committee on special education (CSE): Yes (If yes, please see below) No Does the child have a current individualized education plan (IEP)? Yes (If yes, please provide a copy) No

Does the child have a current 504 plan? Yes (If yes, please provide a copy) No For a Parent/Guardian’s legal rights regarding referral and evaluation for purposes of special education services/programs please visit http://www.p12.nysed.gov/specialed/publications/policy/parentguide.htm or contact Director of Special Education at 716-362-3063.

2. Select one or more races from the following five racial groups. For question (2) check all groups that apply to your child; check at least ONE box.

AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains cultural identification through tribal affiliation or community recognition.

ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent, including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

BLACK OR AFRICAN AMERICAN: A person having origins in any of the Black racial groups of Africa.

WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Student Race and Ethnicity

To the Parent/Guardian: The Amherst Central School District has adopted a policy which requires the collection and recording of the ethnic identity of students in the Amherst

Central School District in accordance with the federal categories and definitions. The information will be used to:

Report information to the State and Federal Education Departments.

Plan educational programs and make sure that they are readily available to all students.

Analyze differences in academic performance, attendance and completion of school.

We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions below. Check the box for the category or categories which best describe your child. The Amherst Central School District understands the sensitive nature of this information and wishes to assure you that it will be kept secure and confidential in accordance with all State and Federal student privacy laws and regulations. If the information requested is not provided on this form on behalf of your child, a student records officer from the school or district will be required to identify the group to which the student appears to belong, identifies with, or is regarded in the community as belonging. Thank you for your cooperation.

Directions to Parent/Guardian: PLEASE ANSWER QUESTIONS (1) AND (2). PLEASE READ THEM BEFORE YOU RESPOND. For question (1) check the box that best describes your child. Check only ONE box. 1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American,

or other Spanish culture or origin, regardless of race.

YES, Hispanic NO, not Hispanic

Student Information

Middle Name Gender Last Grade Last Name First Name or Initial Date of Birth M / F Attended _______________________________________________ ________________________________ ___________ ___________ ________ ________ Resident Address (House #, Street, City, State, Zip, Apartment or Lot#) Mailing Address (If Different) _____________________________________________________________ _______________________________________________________ Student is living with (Check only one): Both Parents Mother Only Father Only Foster Parent (DSS-2999)

Host Family Legal Guardian Parents divorced or separated? Yes No Home Telephone: ___________________________ Cell Phone: __________________________

Has student ever repeated a grade? Yes No If yes, which grade? ____________ Has student lived in ACSD previously? Yes No

Will Transportation be needed for morning? Yes No Afternoon? Yes No Transportation limits for students residing within the Amherst Central School District are as follows: A. All students in grades K-5 will be transported to and from school. B. All students in grades 6-8 who live one mile or more from school will be transported to and from school. C. All students in grades 9-12 who live one and one-half miles from school will be transported to and from school.

Transportation for students enrolled in private, parochial or charter schools: Section 3635 of the Education Law requires all non-city districts to provide transportation

for pupils enrolled in grades K-12 from the school they attend up to a distance of fifteen miles.

New Student Registration Form

Previous Enrollment Information

Former Address (House #, Street, City, State, Zip, Apartment or Lot#) ______________________________________________________________ Previous District & School __________________________________________________________________________________ Previous Grade ____________________

Previous School Phone Number ______________________________________________ Fax Number ______________________________________________________

Previous School Address (to request records) _____________________________________________________________________________________________________

PAGE 1 OF 2

Amherst Central School District

55 Kings Highway

Amherst, NY 14226

Phone (716) 362-3000

Fax (716) 836-2537

Adult 2

Name Prefix: Dr. Mr. Mrs. Ms. Other (Indicate)

Can this person: Yes No Receive mail about student?

Receive email about student?

Pick this student up from school?

Name: _______________________________________________________________

Relationship To Student: Father Mother Step- Step- Relative Non- Father Mother Relative

Legal Guardian: Yes No Gender: Male Female

Address: _____________________________________________________________ (If Different from Student) Occupation: __________________________________________________________ Employer: ____________________________________________________________ Work Phone: _____________________ Cell: _______________________________ Home Phone: ___________________________ Email: _______________________________________________________________

Name: _______________________________________________________________

Relationship To Student: Father Mother Step- Step- Relative Non- Father Mother Relative

Legal Guardian: Yes No Gender: Male Female

Address: _____________________________________________________________ (If Different from Student) Occupation: __________________________________________________________ Employer: ____________________________________________________________ Work Phone: _____________________ Cell: _______________________________ Home Phone: ___________________________ Email: _______________________________________________________________

Name: _______________________________________________________________

Relationship To Student: Father Mother Step- Step- Relative Non- Father Mother Relative

Legal Guardian: Yes No Gender: Male Female

Address: _____________________________________________________________ (If Different from Student) Occupation: __________________________________________________________ Employer: ____________________________________________________________ Work Phone: _____________________ Cell: _______________________________ Home Phone: ___________________________ Email: _______________________________________________________________

Can this person: Yes No Receive mail about student?

Receive email about student?

Pick this student up from school?

Name: _______________________________________________________________

Relationship To Student: Father Mother Step- Step- Relative Non- Father Mother Relative

Legal Guardian: Yes No Gender: Male Female

Address: _____________________________________________________________ (If Different from Student) Occupation: __________________________________________________________ Employer: ____________________________________________________________ Work Phone: _____________________ Cell: _______________________________ Home Phone: ___________________________ Email: _______________________________________________________________

Be advised that providing false information on this registration form may constitute a crime and may be reported to local law enforcement officials. In addition, the District reserves

the right to recover from parents, legal guardians or other responsible parties the entire actual cost of educating a student, plus related costs (including reasonable attorney and

investigator fees), for the entire period that any non-resident student is enrolled in the District’s schools without authorization and/or under false pretenses.

I hereby certify that the student listed on this registration form actually resides at the address specified on page 1, within the Amherst Central School District boundaries. I further

certify that all the information I provided on this registration form is true and correct. I understand that I must immediately notify the District if the residency of the student changes

from the address listed on this registration form.

PARENT/GUARDIAN SIGNATURE: ___________________________________________________________________________________________ DATE: __________________________________

Adult 3

Name Prefix: Dr. Mr. Mrs. Ms. Other (Indicate)

Adult 4

Name Prefix: Dr. Mr. Mrs. Ms. Other (Indicate)

Parent / Guardian Information

Adult 1

Name Prefix:

Dr. Mr. Mrs. Ms. Other (Indicate)

PAGE 2 OF 2

Emergency Contacts Siblings In Same Household

Name: ___________________________________ Ok to pickup student? ________ Relationship: ____________________________ Phone: ____________________ Name: ___________________________________ Ok to pickup student? ________ Relationship: ____________________________ Phone: ____________________

Name: ________________________________ Date of Birth ____________ Gr ______ Name: ________________________________ Date of Birth ____________ Gr ______ Name: ________________________________ Date of Birth ____________ Gr ______ Name: ________________________________ Date of Birth ____________ Gr ______

Can this person: Yes No Receive mail about student? Receive email about student? Pick this student up from school?

Can this person: Yes No Receive mail about student? Receive email about student? Pick this student up from school?

Amherst Central School District 55 Kings Highway Amherst, NY 14226 Phone (716) 362-3000 Fax (716) 836-2537

Enrollment Form

Residency Questionnaire McKinney-Vento Assistance Act

The McKinney-Vento Assistance Act of 1987 is a federal law that provides money for homeless shelter programs.

CONFIDENTIAL INFORMATION

Local Educational Agency (LEA): Amherst Central School District

Name of Student: _________________________________________________________________

School: Smallwood Drive School

Windermere Boulevard School

Amherst Middle School

Amherst High School

Gender:

Male

Female

Date of Birth: __________/ __________/ __________ Grade: _____________________________________________

Address: ____________________________________________

____________________________________________

Phone: _____________________________________________

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 do not have the documents normally needed, such as proof of residency, school records, immunization records, or proof of birthdate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

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 referred to as “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, Guardian or Student Signature of Parent, Guardian or Student (for unaccompanied homeless youth) (for unaccompanied homeless youth)

_________________________________ Date

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 Colon-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 home or 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 Father

specify 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 in English 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 QUALIFIED 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 TEAM MO DAY YR.

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL

NAME: POSITION:

DATE OF NYSITELL

ADMINISTRATION:

PROFICIENCY LEVEL

ACHIEVED ON

NYSITELL: ENTERING EMERGING TRANSITIONING EXPANDING COMMANDING

MO. DAY YR.

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

Amherst Central School District Anthony J. Panella Superintendent

Lynn Shanahan, Ph.D. Assistant   Superintendent   for   Curriculum,   Instruction   and   Technology 

Michael Belle-IsleAssistant Superintendent for Student & Staff Services

REQUEST   FOR   STUDENT   RECORDS   FOR   NEW   ENROLLMENTS 

I   hereby   authorize   the   release   of   school   records   including   academic,   standardized   testing,   cumulative record/transcript,   special   education   and   /   or   504/ADA   information   including   confidential   reports   such   as   a birth   certificate,   immunization   and   health   records   for   my   son/daughter   from   the   following   school: 

Previous   School   Name:   __________________________________________________ 

Address:   ______________________________________________________________ 

City/State/Zip:   __________________________________________________________ 

School   Phone:   _______________________          School   Fax:   ______________________ 

Student   Name:   ______________________________________   DOB:   ______________  

Present   Grade   Level:   _______________                     Last   Grade   Completed:   _______________ 

Parent/Guardian   Signature:   ________________________________________________ 

Please   send   records   to   the   following   in   the   Amherst   Central   School   District   (see   checked   box): 

⃞ Amherst   High   School ⃞ Amherst   Middle   School Student   Services Counseling   Center 4301   Main   Street 55   Kings   Highway Amherst,   NY   14226 Amherst,   NY   14226 Phone:   716­362­8175 Phone:   716­362­7177 Fax:  716­836­4972 Fax:  716­836­0193 

⃞ Smallwood   Drive   Elementary ⃞ Windermere   Boulevard   Elementary 300   Smallwood   Drive 291   Windermere   Boulevard Amherst,   NY   14226 Amherst,   NY   14226 Phone:716­362­2100 Phone:716­362­4100 Fax: 716­839­3578 Fax: 716­838­3764 

⃞ Amherst   Central   School   District   ­   Special   Ed.   Records   (IEP,   Psychological,   etc.) Office   of   Special   Education 55   Kings   Highway Amherst,   NY   14226 Phone:716­362­3063 Fax: 716­836-2537 

55   Kings   Highway,   Amherst,   NY   14226­4330  ◆  Phone:   716­362­3000  ◆  Fax:   716­836­2537  ◆   www.amherstschools.org 

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.