Woodland Park Public Schools
Grades 1-8
Registration Packet
2015-2016
Revised: January 2015
SCHOOL YEAR
WOODLAND PARK PUBLIC SCHOOLS
OFFICE OF THE SUPERINTENDENT
853 McBride Avenue, Woodland Park, New Jersey 07424
Dr. Michele Pillari
Superintendent of Schools
Email: mpillari@wpschools.org
Telephone: 973-317-7710
Woodland Park Schools –Registration Notice
When registering you children into the Woodland Park Public Schools for the 2015-2016 school year, parents must
present the following for admission:
1. Original Birth Certificate with Raised Seal
2. Proof of Residency:
Homeowners – 3 documents are required:
. Mandatory: Deed, Affidavit of Title, HUD Settlement Statement, Certification of Occupancy, Mortgage
Statement or Current Tax Bill Statement
.
.
.
.
Current utility bill
Voter Registration Card,
Valid Driver’s License or photo ID of the parent/guardian
Current Bank Statement
Renters – 3 documents are required:
. Mandatory: Current (not expired lease) or notarized letter from landlord (affidavit of domicile)
. Current utility bill
. Voter Registration Card
. Valid Driver’s License or photo ID of the parent/guardian
. Current Bank Statement
3. Proof of the following vaccinations, as required by New Jersey Law:
DPT – a minimum of four doses with one dose administered on or after the fourth birthday or any
5 doses.
Polio – a minimum of three doses provided at least one dose is given on or after the fourth birthday
or any four doses.
Measles – two doses vaccine with the first dose given on or after the first birthday.
Mumps – administered on or after the first birthday.
Rubella – administered on or after the first birthday.
Varicella – administered on or after the first birthday.
Hepatitis – three doses vaccine.
Physical examinations are required for all new students before entering school. This exam must be recorded on a
school form, which will be available at registration or the district’s website: wpschools.org. The exam must be
done no more than 365 days prior to entrance. If your child’s yearly physical exam is not due until after the
registration dates, please bring a copy of their latest immunization record when you register so it can be reviewed
by the school nurse.
Dr. Michele Pillari, Superintendent
853 McBride Avenue
Woodland Park, New Jersey 07424
Woodland Park Public Schools
Registration Check List
Student’s Name:________________________________________
Date:_____/____/_____
Address: _____________________________________________________________________
Parent’s Name_______________________________
Mother/Guardian
_______________________________
Father/Guardian
Home Phone # _______________________
Cell Phone#________________________
-----------------------------------------------------------------------------------------------------------------This section
FOR OFFICE USE ONLY_
Documentation of Residency:
_____ Rent Receipt
_____PSEG Bill
_______Lease
______Tax Bill
______Mortgage Statement
______Phone ______Driver’s License _________________Other
_____Registration Form
_____Emergency Form
_____Birth Certificate
_____Medical Questionnaire
_____Immunization Records
_____Release of Records
_____School Medical Examination Form
_____TB Test Form
_____Transfer Card
Student is Classified - Y ____ N ____
Types of Services _______________________________________________________
* If student is classified copy of this form must be sent to CST
______ Initial of Registrar
Grade _________
Homeroom ____________________ Date of Admittance ________
School Year 20__-20__
WOODLAND PARK PUBLIC SCHOOLS
ENROLLMENT INFORMATION
ALL AREAS MUST BE COMPLETED
STUDENT NAME:______________________________________________SEX:________GRADE:________
ADDRESS:____________________________________________________ DATE:____________________
DATE OF BIRTH:____________________AGE:________PLACE OF BIRTH:______________________
**IF PARENTS ARE DIVORCED, WHO HAS RESIDENTIAL CUSTODY:_________________________
In order for the Woodland Park Public Schools to comply with the Federal Government’s request for
racial/ethnic information, please fill out the following section. This information is for reporting purposes
only. Please check one:
_____American Indian/Alaskan Native, origins in any of the original peoples of North America.
_____Asian/Pacific Islander, origins in any of the original peoples of Far East, Southeast Asia, Japan,
Pacific Islands or Indian Subcontinent.
_____Black, Non-Hispanic
_____White, Non-Hispanic, origins in any of the original peoples of Europe, North Africa or Middle East.
_____Hispanic, persons of Mexican, Cuban, Central American or other Spanish culture or origin
regardless of Race.
LEGAL PARENT/GUARDIAN INFORMATION:
FATHER:_____________________________________MOTHER:___________________________________
ADDRESS:____________________________________ADDRESS:___________________________________
CITY/STATE:__________________________________CITY/STATE:_______________________________
HOME PHONE:_______________________________HOME PHONE:_______________________________
CELL PHONE:__________________________________CELL PHONE:______________________________
WORK PHONE:________________________________ WORK PHONE:______________________________
EMERGENCY CONTACT:_________________________PHONE:_______________________________________
RELATIONSHIP:_____________________________________ EMAIL:___________________________________
TYPE OF DWELLING:
____1 Family ____2 Family ____Multiple Family
# of Rooms_____ # of Bedrooms_____ # of Adults living in home _____ # of children living in home_____
PREVIOUS SCHOOL ATTENDED:__________________________________________________________
NAME OF TOWN:_________________________________________________________________________
LAST GRADE ATTENDED:_________________________________
(Continued)
Please answer the following questions for NJSMART:
1. Home Language spoken by student _____________________________________
2. What is student’s immigrant status _____________________________________
3. When was student’s first entry date into a U.S. School______________________
4. Homeless Y____ N______
5. If Homeless, indicate Primary Nighttime Residence_________________________
6. Does your Child have Health Insurance Y______ N______
7. Name of Health Insurance Carrier________________________________________
School Year 20__- 20___
WOODLAND PARK PUBLIC SCHOOLS
WOODLAND PARK, NJ 07424
WOODLAND PARK PUBLIC SCHOOLS MEDICAL QUESTIONAIRE
STUDENT NAME:_______________________________________GRADE:_______________________
FAMILY DOCTOR:______________________________________TELEPHONE:____________________
FAMILY DENTIST:______________________________________TELEPHONE:____________________
The school nurse would like parents of all new students to answer the following questions so the best
medical care may be provided for your child.
1. Is your child allergic to anything, if yes, please list:____________________________________
______________________________________________________________________________
2. Does any food, medicine or environmental items cause difficulty in breathing? Y____N_____
If yes, please list________________________________________________________________
3. Has your child ever had a seizure or convulsion? Yes_____No_____
If yes, when _____________how often_______________date of last seizure_______________
4. Does your child take any medication, if yes, please list name and purpose for taking medication
_______________________________________________________________________________
_______________________________________________________________________________
5. Will your child be taking any medication at school on a daily basis, if yes, please list name of
the medication__________________________________________________________________
6. Has your child ever been hospitalized for any illness or accident? If yes, please describe what type of
accident/injury your child was treated for:______________________________________________
7. Has your child every had a head injury, fractures, or broken bones, if yes, please describe –
________________________________________________________________________________
8. Has your child ever had any surgery? If yes, please list ____________________________________
__________________________________________________________________________________
9. If there is a problem with (please check any that apply)
Vision _____ Hearing _____ Speech _____ Physical Activity _________________________________
*Please explain if you checked any of above______________________________________________
10. Is there a family history of heart problems, cancer or diabetes? Yes _____ No _____
11. Is your child afraid of anything? (i.e. animals, dark, thunder) Yes _____ No _____
___________________________________________________________________________________
12. Does your child have any problems or illness? Yes _____ No_____ If yes, please note –
13. If your child is seriously injured, and school personnel is unable to contact you, may school
personnel
have an ambulance transport your child to the emergency room? Yes _____ No _____
14. Has your child had a Lead Test? Date of Test _____________What was the level?________________
___________________________________________
Parent/Guardian Signature
School Year 20__ - 20___
________________________________________
Date
Woodland Park Public Schools
853 McBride Avenue
Woodland Park, NJ 07424
ALL AREAS MUST BE COMPLETED
SCHOOL HEALTH SERVICES
Dear Parents;
As part of the School Health Program, it was recommended that your child have an annual physical examination by your family physician.
However, the policy in Woodland Park requires all new students and students in Kindergarten to have a physical examination.
It is recommended that these examinations be performed by your family physician. Your physician’s knowledge of your child makes him
best qualified to interpret the information necessary to improve the child’s health. The family physician can assist the school in making
adjustments in the education program for your child.
A medical examination performed during the summer is acceptable, (P.A.L. sports, camp physicals, working paper physicals, etc.)
Michele R. Pillari, Ed.D.
Superintendent of Schools
-----------------------------------------------------------------------------------------------------------------------------PARENT NOTIFICATION FOR TUBERCULIN TESTING
A Tuberculin Test is required by the Rules of the State Board of Education
and New Jersey Law.
Your child needs to have a Tuberculin test as part of the physical.
If you have records of information about a previous tuberculin reaction, chest x-ray, B.C.G. vaccination, cortisone or if your child has
been immunized against measles, mumps, polio, rubella (German Measles) or small pox in the past six weeks, please notify the school
nurse.
_____________________________________
Signature of Parent/Guardian
School Year 20__-20__
__________________
Date
Woodland Park Public Schools
853 McBride Avenue
Woodland Park, NJ 07424
FOR DOCTOR ONLY
.SCHOOL EXAMINATION FORM
Student’s Name_________________________________________ Age_________
Grade____________
Student’s Address_______________________________________________________________________
D.O.B.___________ Parent’s Name_________________________________ Phone#__________________
Physical Report:
Ht._______ Wt._______ BP________
Eyes: R20/______ L20/______ Ears: Hearing R_____ L_____
Respiratory____________________________________________________________________________
Cardiovascular_________________________________________________________________________
Abdomen___________________________________ Genitalia__________________________________
Scoliosis______________________________________________________________________________
Musculoskeletal______________________________ Skin______________________________________
Neurological___________________________________________________________________________
Immunizations:
___
___
___
DPT DPT DPT
___
DPT
___
DPT
___
DPT
___
___
___ ___ ___ ___
OPV OPV OPV OPV OPV OPV
___ ___ ___ ___ ___ ___
TET TET HIB HIB HIB HIB
__________
Measles (live)
______ _______
TB Tine Mantoux
Results____________________
_______________
Meningococcal
______________
Influennza
______ ______
Mumps Rubella
____ _____ _____
Hep B Hep B Hep B
_______
MMR #2
______________ _________
Varicella Vaccine / had disease
Recommendations:
1. Any defect of vision, hearing, or speech that the school could compensate for
by proper seating, Etc?
2. Any condition limiting classroom activity?
3. Any condition limiting Physical Education?
4. Any significant allergies?
5. Any condition, which may result in a classroom emergency?
6. Any emotional, mental or physical condition requiring periodic medical
observation?
7. Is child currently on medication?
Give directions, to school if applicable.
_____________
Lead Test
Yes
No
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Comments:_____________________________________________________________________________
______________________________________________________________________________________
_______________________________________
________________
Physician’s Signature and Stamp
Date of Physical
School Year 20__-20__
Woodland Park Public Schools
853 McBride Avenue
Woodland Park, NJ 07424
ALL AREAS MUST BE COMPLETED
RELEASE OF RECORDS
To:________________________________________
Date:_____________
(Previous School)
________________________________________
(Street Address)
_________________________________________
(City & State)
Telephone #______________
(Zip Code)
Child’s Name:________________________________ Grade:______ D.O.B.__________
The student listed above has enrolled in our school. Please send entire cumulative information:
_______Medical or Health Records
_______Test Records
_______Scholastic Achievement Records
_______Child Study Team Records
_______Confidential File
_______Transfer
_______________ State Identification Number (SID)
Please forward to:
Beatrice Gilmore School
1075 McBride Avenue
Woodland Park, NJ 07424
Charles Olbon School
50 Lincoln Lane
Woodland Park, NJ 07424
Memorial School
15 Memorial Drive
Woodland Park, NJ 07424
If the student left during a grading period, please indicate withdrawal grades earned for that period.
Any further information you can give us to help in proper placement will be appreciated. If these records are
not available at your school, Please advise accordingly.
Thank you for your cooperation.
I give my permission for the release of the records on the above student.
________________________________
________________
Signature of Parent/Guardian
Date
School year 20____ - 20____
Woodland Park Public School District
2015-2016 School Year
(In Compliance with New Jersey State Legislature Bill A592)
Parental/Guardian Consent Form
We are sending you this parental consent form to both inform you and to request permission for your child’s photo/image
and personally identifiable information to be published on the district and/or school’s web site.
As you are aware, there are potential dangers associated with the posting of personally identifiable information on a web site
since global access to the Internet does not allow us to control who may access such information. These dangers have
always existed; however, we as schools do want to celebrate your child and his/her work. The law requires that we ask for
your permission to use information about your child.
Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent
or guardian. Personally identifiable information includes student names, photo or image, residential addresses, e-mail
address, phone numbers and locations and times of class trips.
If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to
the principal of your child’s school and such rescission will take effect upon receipt by the school.
Check one of the following choices:
I/We GRANT permission for a photo/image that includes this student without any other personal identifiers to be
published on the school and/or district’s public Internet site.
I/We DO NOT GRANT permission for photo/image that includes this student to be published on the school and or
district’s public Internet site.
Student’s Name: (please print) _____________________________________
Student’s School ______________________________________ Student’s Grade: ________
Print name of Parent/Guardian: (print) _________________________________________________
Signature of Parent/Guardian: (sign) __________________________________________________
Relation to Student: _______________________________________ Date: __________________