Today’s Date: ___________
Perm # __________________
Passport # _______________
Grade: ________
Teacher: __________________
Room # _______
Assigned Schl: _____________
Resident Schl: _____________
Entry Date: __________
YOG: ______________
NEW LONDON PUBLIC SCHOOLS
NEW LONDON, CONNECTICUT
2015-2016
STUDENT REGISTRATION DATA
(PreK-5)
Student’s Name
Last
First
Middle
(Jr./Sr./I/II)
1.
Social Security Number (Optional)
____________________________________________
2.
Mailing Address
____________________________________________
3.
City
4.
Home Tel# with Area Code
____________________________________________
5.
Birth Date (mm/dd/yy)
________________
6.
Place of Birth
____________________________________________
7.
Country of Citizenship
United States
8.
Date first entered the United States (mm/dd/yy)
____________________________________
9.
Language to use for written correspondence:
____________________________________
10.
Is your child Hispanic/Latino?
11.
State
Zip
____________________________________________
Sex:
M
F
Other: _______________________
Yes
No
What is your child’s race? (Circle one or more, even if you answered “yes” to the Hispanic/Latino question.)
(I)
(A)
(B)
American Indian/Alaskan Native
Asian
Black or African American
(P) Native Hawaiian or Other Pacific Islander
(W) White
Female Guardian Information:
12.
Relationship of Female Guardian:
Mother
Legal Guardian
13.
Does the above live with you?
14.
Last Name
___________________________________________
15.
First Name
___________________________________________
16.
Middle Name
___________________________________________
17.
Maiden Name
___________________________________________
18.
Salutation
Mrs.
19.
Address
___________________________________________
20.
City State Zip
___________________________________________
21.
Telephone #
___________________________________________
22.
Cell #
___________________________________________
23.
Employer/Not Employed
___________________________________________
24.
Occupation
___________________________________________
25.
Work Tel#
___________________________________________
26.
Work Extension
___________________________________________
27.
Work Address
___________________________________________
28.
E-Mail Address
___________________________________________
Yes
Ms.
Other _____________
No
Other _______________
Student’s Name: ______________________
Male Guardian Information
29.
Relationship of Male Guardian:
30.
Does the above live with you?
31.
Last Name
____________________________________________
32.
First Name
____________________________________________
33.
Middle Name
____________________________________________
34.
Salutation
Mr.
35.
Address
____________________________________________
36.
City
37.
Telephone#
____________________________________________
38.
Cell #
____________________________________________
39.
Employer/Not Employed
____________________________________________
40.
Occupation
____________________________________________
41.
Work Tel#
____________________________________________
42.
Work Extension
____________________________________________
43.
Work Address
____________________________________________
44.
E-Mail Address
____________________________________________
State
Zip
Father
Legal Guardian
Yes
Other _______________
No
Other ________________________
____________________________________________
Emergency Contact Information – Other than Parent/Legal Guardian
45.
Name of 1st Emergency Contact
____________________________________________
46.
Relationship
____________________________________________
47.
1st Contact’s Home Telephone #
____________________________________________
48.
1st Contact’s Cell #
____________________________________________
49.
1st Contact Work #
____________________________________________
50.
Contact’s Address
____________________________________________
51.
City
____________________________________________
52.
Name of 2nd Emergency Contact
____________________________________________
53.
Relationship
____________________________________________
54.
2nd Contact’s Home Telephone #
____________________________________________
55.
2nd Contact’s Cell #
____________________________________________
56.
2nd Contact’s Work #
____________________________________________
57.
2nd Contact’s Address
____________________________________________
58.
City
____________________________________________
State
State
Zip
Zip
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Student’s Name: ______________________
ADDITIONAL INFORMATION:
___________________________________________
Name of adult(s) authorized
to pickup student from school.:
___________________________________________
I authorize the emergency contacts listed on page 2 to pickup my student ____________________________
Signature of Parent/Guardian
Name of the last school your child attended:
___________________________________________
City/State
_________________________________________________________________
Grade
____________
Year
Has your child ever attended the NL Public Schools?
__________
Yes
No
If so, which school _________________________________________________________
Grade
____________
Year
Are you in the military?
___________
Yes
Does your child receive Special Education services:
Yes
Has your child previously received Special Education services: Yes
No
No
Date discontinued _______
No
Other children living in your home:
Name
DOB
School Currently Attending
Grade
___________________________
______________
___________________________
______
___________________________
______________
___________________________
______
___________________________
______________
___________________________
______
___________________________
______________
___________________________
______
___________________________
______________
___________________________
______
HOME LANGUAGE SURVEY:
What is the primary language spoken by your child at home?
_________________________________
What is the primary language spoken by you or other persons in your home? _____________________
What language did your child learn to speak first?
________________________________________
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Student’s Name: ______________________
PRESCHOOL AND CHILD CARE INFORMATION:
Has this student attended a preschool center or home child care program?
Yes
_____
No
_____
If yes, name of center:_________________________________________________________________
And how long did child attend? ___ 2 Years
Will this student receive after school child care?
___ 1 Year
Yes
___ Less than 6 months
_____
No
_____
If yes, name of child care provider: ______________________________________________________
______________________________________________________
_____________________
Address
Telephone
HEALTH INSURANCE:
Does your child have health insurance:
If no, would you like information about the HUSKY Plan?
Yes
Yes
No
No
MEDICAL INFORMATION/AUTHORIZATION:
Permission is hereby granted to New London Public School authorities to procure emergency medical, dental and/or
hospital evaluation, care and/or treatment for my child if I cannot be contacted in an emergency.
_______________________________________________________
Signature of Parent/Guardian
_________________
Date
TECHNOLOGY POLICY:
I am aware of the NLPS’ Policy on Technology and Instruction: Acceptable Use of the Computer Network:
_______________________________________________________
Signature of Parent/Guardian
________________
Date
DISCLAIMER:
I certify that the above information is true, complete and accurate. I understand that willfully providing false
information to the New London Public Schools is a violation of the law.
_______________________________________________________
Signature of Parent/Guardian
________________
Date
PARENTS ARE REMINDED TO INFORM THE SCHOOL IMMEDIATELY IF ANY OF THE
ABOVE INFORMATION CHANGES DURING THE COURSE OF THE SCHOOL YEAR.
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Student’s Name: ______________________
SCHOOL USE ONLY
Date: __________________
Please fill in all information or circle appropriate response:
Proof of:
Address
Birth
Health Reqs.
Yes
Yes
Yes
No
No
No
Special Services – C File Yes
No
Homeless:
Yes
Date: ________
Dominant Language
Kindergarten Session:
Lunch:
Transportation:
Bus Stop:
AM Bus #
PM Bus#
Free
_________________
FDK
AM
PM
Reduced
Paid
Walker
Bus
______________________
___________
___________
Notes: _____________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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