NATICK PUBLIC SCHOOLS - NEW STUDENT INFORMATION FORM
FOR OFFICE USE ONLY
State ID#:
Grade
YOG
Local ID#:
HR/COMM
SEM
COUNSELOR
SPED
Y
N
ENTRY RECORD
PCC Code:
Entry (First) Date:
School Official:
504
Y
LOCKER #
METCO
N
Y
N
MCAS
ELA – MATH
SCIENCE
Y
N
ELL
Y N
Coming From:
Date:
REGISTRATION FORM BEGINS HERE
Name should be as recorded on birth certificate or other legal document
Student Name: ____________________________________________________________________________________________________
Full Last
Full First
Full Middle
Nickname
Natick Home Address: ______________________________________________________________________ ________________________
Number
Street
Apt.
Town
State
Zip
Mailing Address: ___________________________________________________________________________________________________
If Different
Number
Street
Apt.
Town
State
Zip
Home Phone: __________________ _______ Grade: _______ ___Has student ever attended Natick Public Schools? __________________
Date of Birth: ____________________________ City/Town of Birth: _____________________________State: ________Gender M
F
Bilingual: Y N ESL: Y N Primary Language: English or __________________________________
In what country was the student born? __________________________________________________________________________________
If the student was born outside of the United States, what was the date of first entry to the United States?_________________________
Number of years of schooling completed in USA: ____________Number of years of schooling in home country: ____________
Highest year completed in home country: ____________ What year did your child begin school in the US?_________________
Who is the legal guardian of this student? Parents  Mother Only  Father Only  Guardian  Other________________________
With whom does this student reside? Parents  Mother Only  Father Only  Guardian  Other_________________________ __
Is there a Custodial Agreement pertaining to this student? Yes  (Please provide a copy) No  NOTE: ___________________________
What is the Primary Number at which we can contact you during the day? (Our Robocall system will use this number as contact)
#____________________________________________________
1
Previous School Information
Last school attended: ___________________________________________________ City: __________________________State: ________
Please check any additional services the student was receiving:
 Student has an Individual Education Plan
 Student has a 504 plan
Has the student previously taken the MCAS (Massachusetts Comprehensive Assessment System) Test or PARCC? YES  NO 
Date of last MCAS/PARCC: _______________________ Name of school where taken: ___________________________________________
The Massachusetts Department of Education requires districts to collect the following demographic data for each student.
Ethnicity and race definitions are as defined by the federal Office of Management and Budget (OMB).
Ethnicity – Is student Hispanic or Latino? Select only one
 No, not Hispanic or Latino
 Yes, Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
What is the student’s race? Select one or more
 White: a person having origins in any of the original peoples of Europe, the Middle East, or North America.
 Black or African American: a person having origins in any of the black racial groups of Africa.
 American Indian or Alaskan Native: a person having origins in any of the original peoples of North and South America (including Central America), and who
maintains tribal affiliation or community.
 Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, 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____________
No Child Left Behind
Under the “No Child Left Behind Act,” all military recruiters are entitled to a list of the names, addresses, and telephone numbers of
students. We are required under the law to provide these lists to them upon request. Parents/Guardians may, however, request that their
child’s name be removed from these lists by checking the box below and signing this form.
 Do not release my child’s name and contact information
Parent Signature: __________________________________________________________________________________________________
Military Family Status
There is a Parent or Guardian in the student’s household who: (Please check the box that applies.)
 is an active duty member of the uniformed services, National Guard and Reserve on active duty orders.
 is a veteran who retired within the past year.
 was medically discharged within the past year.
 died while serving our country within the past year.
 Other: ____________________________________
Date of discharge, retirement, death, deployment, military transfer, etc. _____________________________________________________
Student Name: _______________________________________________ School Attending: _____________________________________
Name of Service Member: _______________________________________________________
Name of Person completing this form: ___________________________________________________________ Date: ______________
I hereby certify that all the above information is accurate: ___________________________________________Date:__________________
Parent/Guardian Signature
2
Emergency and Legal Guardian Information
Student Name______________________Teacher_______________
can pick up 
First Parent/Guardian Information:
can dismiss 
NOTES: Office Staff Only
Name: ___________________________________________________________________ Relationship: _____________________________
Address: __________________________________________________________________________________________________________
Number
Street
Apt.
Town
State
Zip
Home Phone: ____________________________________ Unlisted: YES  NO  Cell: _______________________________________
Email: _________________________________________Employer: _____________________________Work Phone: __________________
Parent/ Guardian Primary Language:____________________ Requires communication in:  English or  Other ___________________
can pick up 
Second Parent/Guardian Information:
can dismiss 
Name: ___________________________________________________________________ Relationship: _____________________________
Address: _________________________________________________________________________________________________________
Number
Street
Apt.
Town
Home Phone: ____________________________________ Unlisted: YES  NO 
State
Zip
Cell: _____________________________________
Email: _________________________________________Employer: _____________________________Work Phone: __________________
Parent/ Guardian Primary Language:____________________ Requires communication in:  English or  Other ____________________
*IN CASE OF EMERGENCY: While every attempt will be made to reach a student’s parent/guardian in an emergency, in the event that we can’t reach you,
we ask that you provide us with emergency contact information.
Please indicate local contacts that have permission to receive and dismiss students in the event of an emergency.
Emergency Contact Information
1st Emergency Contact:
can pick up 
can dismiss 
NOTES:
Name: ___________________________________________________________________ Relationship: ___________________________
Address: ________________________________________________________________________________________________________
Number
Street
Apt.
Town
State
Zip
Home Phone: __________________________ Cell: _________________________ Work Phone: _________________________________
can pick up 
2nd Emergency Contact:
can dismiss 
Name: ___________________________________________________________________ Relationship: ___________________________
Address: ________________________________________________________________________________________________________
Number
Street
Apt.
Town
State
Zip
Home Phone: __________________________ Cell: _________________________ Work Phone: _________________________________
(OVER)
3
HEALTH HISTORY *
STUDENT NAME_____________________________________ DOB:_______________
Does your child have health insurance Yes No Health Insurance _______________ Does your child have dental insurance Yes No Dental Insurance _____________
Please list all medications that your child takes:
______________________________________________________________________________________________________________________________
Please check all that apply to your child:
Heart condition
Diabetes
Asthma
Seizure Disorder
ADD/ADHD
Migraines Depression
Other(specify)____________________________
Allergies (food, insects, medication, environment – specify) ______________________________________________
Hearing problems (specify)
left ear_____
right ear_____
hearing aids_________
Vision problems (specify)
wears glasses ________
contact lenses __________
In case of emergency, the school will attempt to contact parent/guardian before calling student’s primary care provider (physician). Your child will be transported by ambulance to an
emergency care facility if necessary.
Physician Name ____________________________ Phone (___)_________________
Date of Last Exam: ___________________
Dentist Name ____________________________
Date of Last Exam: ___________________
Phone (___)_________________
ACETAMINOPHEN (generic Tylenol) PROTOCOL / PERMISSION
1.
2.
Acetaminophen will only be given with this signed permission of the parent/guardian.Telephone permission is NOT ACCEPTED.
After the nurse assesses the student, acetaminophen will only be given for minor discomfort such as; occasional headache, menstrual cramps or orthodontic braces. IT WILL NOT
BE GIVEN FOR AN ELEVATED TEMPERATURE OR PAIN OF A SERIOUS NATURE.
3. Acetaminophen will only be given once during the school day.
4. The nurse will:
 Assess the student’s condition and
 Review the
For preschool through Grade 4 students, the nurse will
At the middle and high
Acetaminophen will be
evaluate the need for medication.
permission slip.
CALL the parent/guardian. If unable to reach
school level,
given according to the
parent/guardian and 4 hours have elapsed since school
Acetaminophen will be
guidelines established by
started, Acetaminophen will be given.
given at the nurse’s
the school physician.
discretion.
*NOTE: This page should only be housed in the nurse’s office and files.
 I give permission for my child to receive Acetaminophen one time during the school day.
 I do not give permission for my child to receive Acetaminophen one time during the school day.
I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school and/or emergency medical personnel
when needed to meet my child’s health and safety needs. I give permission to exchange information with my child’ primary care physician for the purpose of
referral, diagnosis and treatment.
_____________________________________________
____________________
(Parent/guardian signature)
(Date)
4
NATICK PUBLIC SCHOOLS
STUDENT REGISTRATION
HEALTH INFORMATION
STUDENT’S NAME: _____________________________________________________________________________ GENDER: _________
(Last)
(First)
(Middle)
DATE OF BIRTH: _____________________
AGE AS OF AUGUST 31st: _________________________________
NAME OF LAST SCHOOL ATTENDED: _____________________________________________________________
HAS YOUR CHILD EVER BEEN A STUDENT IN NATICK PUBLIC SCHOOLS? YES___________ NO____________
PARENT/GUARDIAN’S NAME: ____________________________________________________________________
PARENT/GUARDIAN’S NAME: ____________________________________________________________________
PARENTS ARE (please circle):
SIBLINGS’ NAMES AND AGES:
MARRIED NOT MARRIED DIVORCED SEPARATED WIDOWED OTHER
_______________________ AGE: _________
_______________________ AGE: _________
_______________________ AGE: _________
_______________________ AGE: _________
OTHERS IN HOUSEHOLD & RELATIONSHIP TO STUDENT:
_____________________________________________________________________________________________
IS STUDENT COVERED BY HEALTH INSURANCE?
YES __________
NO _________
INSURANCE COMPANY NAME: __________________________________________________________________
STUDENT’S PEDIATRICIAN: _____________________________________________ PHONE: ________________
DATE OF LAST COMPLETE PHYSICAL EXAM: ______________________________________________________
PLEASE ATTACH A COPY OF YOUR CHILD’S MOST RECENT PHYSICAL EXAM.
IS YOUR CHILD CURRENTLY TAKING ANY MEDICATIONS? YES ______ NO ______ If yes, please list:
_____________________________________________________________________________________________
IS YOUR CHILD UNDER THE CARE OF A VISION OR HEARING SPECIALIST OUTSIDE OF SCHOOL?
YES: ______ NO: ______ IF YES, PHYSICIAN NAME: _________________________________________________
REASON: _____________________________________________________________________________________
STUDENT’S DENTIST: __________________________________________________ PHONE: ________________
5
STUDENT HEALTH INFORMATION
PAGE 2
ANY SIGNIFICANT BIRTH HISTORY/COMPLICATIONS (please explain):______________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
CURRENT/PAST HEALTH HISTORY:
PLEASE CHECK ANY THAT APPLY TO YOUR CHILD AND EXPLAIN BELOW
______ ADD/ADHD
______ Bleeding Disorders
______ Cardiac Condition
______ Ear Infections/Tubes
______ Head injury
______ Psychiatric History
______ Allergies* (see below)
______ Bone/Joint Conditions
______ Diabetes
______ Eating Issues
______ Hepatitis
______ Seizures
_______ Asthma* (see below)
_______ Bowel/Bladder Problems
_______ Dietary Restriction(s)
_______ Headache/Migraines
_______ Neurological Disorder(s)
_______ Skin Conditions
____ OTHER
COMMENTS ON ANY OF THE ABOVE: ____________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
FOR CHILDREN WITH ASTHMA: Please list known asthma triggers: ______________________________________
DOES YOUR CHILD USE AN INHALER?
YES ______ NO: ______ HOW OFTEN?: _________________
PLEASE REFER TO THE NPS WEBSITE AND REVIEW OUR MEDICATION POLICY AND PROCEDURES.
ALLERGY INFORMATION
DOES YOUR CHILD HAVE ANY ALLERGIES? PLEASE CHECK ALL THAT APPLY:
_____
FOODS PLEASE LIST: ________________________________________________________________
_____
MEDICATIONS PLEASE LIST: ___________________________________________________________
_____
INSECTS PLEASE LIST: ________________________________________________________________
_____
LATEX
_____
ENVIRONMENTAL/SEASONAL PLEASE LIST: ______________________________________________
_____
OTHER PLEASE LIST: _________________________________________________________________
ALLERGIST’S NAME: _________________________________ DATE OF LAST APPOINTMENT: ____________
6
STUDENT HEALTH INFORMATION
PAGE 3
MY CHILD MAY SIT AT THE SAME TABLE WITH CHILDREN EATING THE FOOD(s) LISTED ABOVE:
YES ______ NO ______
HAS YOUR CHILD EVER REQUIRED ADMINISTRATION OF AN EPI-PEN? YES ______ NO ______
WILL YOUR CHILD HAVE AN EPI-PEN AT SCHOOL?
YES ______ NO ______
PLEASE REFER TO THE NPS WEBSITE AND REVIEW OUR MEDICATION POLICY AND PROCEDURES.
ADDITIONAL INFORMATION:
Incidents such as the birth of a sibling, serious accidents or illnesses, death, separation or divorce often affect a child’s behavior in school.
Feel free to comment in the space provided below or indicate a desire to speak privately with a staff member about any emotional issues or
concerns. This information will only be shared with principal, guidance and teachers as needed to support your child.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PARENTS ARE ASKED TO MAKE AN APPOINTMENT TO SPEAK TO THE SCHOOL NURSE REGARDING ANY
SIGNIFICANT HEALTH ISSUES OR CONCERNS.
PLEASE CHECK THE APPROPRIATE BOX BELOW:
________ YES, I WOULD LIKE A PERSONAL APPOINTMENT WITH THE SCHOOL NURSE
________ NO, I DO NOT NEED TO SPEAK WITH THE SCHOOL NURSE
_______________________________________________________
Parent /Guardian
(Print Name)
_______________________________________________________
Parent/Guardian
(Signature)
__________________________
Date
__________________________
Phone Number
7
NATICK PUBLIC SCHOOLS
HOME LANGUAGE SURVEY FORM
Student Name:_______________________________
Address:____________________________________
Date of Birth:___________________ Age:_________
Country of Birth:___________________
Highest Grade Completed:____________
Date Completed:___________________ Date of Entry into US Schools___________
Dear Parent:
A. Please check the appropriate box indicating the language you understand best:
□ E-English
□ S-Spanish
□ C-Cantonese
□ I-Italian
□ F-French
□ H-Haitian
□ K-Cape Verdean
B.
□ P-Portugese
□ G-Greek
□ V-Vietnamese
□ R-Russian
□ M-Mandarin
□ T-Toishanese
□ B-Burmese
□ A-Arabic
□ Q-Korean
□ D-Cambodian
□ L-Laotian
□ W-H’Mong
□ O-Other (Specify)_______
As part of our effort to provide equal educational opportunities for students in the Natick Public Schools, we need to know the language(s) you and
your child speak at home and in your neighborhood. Please answer the questions below. Please complete a separate form for each child.
1.
What language (s) are spoken and/or understood by people living in your home?
□ E-English
□ S-Spanish
□ C-Cantonese
□ I-Italian
□ F-French
□ H-Haitian
□ K-Cape Verdean
2.
□ 4. Mostly the home language (not English) indicated in question #1.
□ 5. Only the home language (not English) indicated in question #1.
□ 4. Mostly the home language (not English) indicated in question #1.
□ 5. Only the home language (not English) indicated in question #1.
What language does our child use when speaking with other family members?
□ 1. Only English
□ 2. Mostly English
□ 3. Both English and other language
6.
□ A-Arabic
□ Q-Korean
□ D-Cambodian
□ L-Laotian
□ W-H’Mong
□ O-Other (Specify)_______
What language does your child use when speaking with brothers and sisters?
□ 1. Only English
□ 2. Mostly English
□ 3. Both English and other language
5.
□ P-Portugese
□ G-Greek
□ V-Vietnamese
□ R-Russian
□ M-Mandarin
□ T-Toishanese
□ B-Burmese
What language does your child use when speaking with you?
□ 1. Only English
□ 2. Mostly English
□ 3. Both English and other language
4.
□ A-Arabic
□ Q-Korean
□ D-Cambodian
□ L-Laotian
□ W-H’Mong
□ O-Other (Specify)_______
What was the first language your child spoke?
□ E-English
□ S-Spanish
□ C-Cantonese
□ I-Italian
□ F-French
□ H-Haitian
□ K-Cape Verdean
3.
□ P-Portugese
□ G-Greek
□ V-Vietnamese
□ R-Russian
□ M-Mandarin
□ T-Toishanese
□ B-Burmese
□ 4. Mostly the home language (not English) indicated in question #1.
□ 5. Only the home language (not English) indicated in question #1.
What language does your child use when speaking with friends in the neighborhood?
□ 1. Only English
□ 2. Mostly English
□ 3. Both English and other language
□ 4. Mostly the home language (not English) indicated in question #1.
□ 5. Only the home language (not English) indicated in question #1.
Parent Signature___________________________ Date:___________ Signature of Verifier:_________________________________
8
Media/Google Apps Accounts Permission Form
Parents / Guardians: Occasionally during school events, photographs or videotapes are made. The photos or videos are
sometimes used to publicize special activities at the school. The purpose of this communication is to gain your permission to
use, in appropriate school related publications, social media or the local newspapers, photographs that might be taken that
include your child.
I DO _____ I DO NOT _____ grant permission to Natick Public Schools to include my child’s image in school related
publications including websites, blogs and other school curated social media.
Child’s name ______________________________________Homeroom #/Teacher Name______________________________
Parent / Guardian’s signature _____________________________________________________Date: ____________________
AND USE OF SCHOOL GOOGLE ACCOUNTS
I give my consent for my son/daughter to access and use Google Apps Education Edition managed by the Natick Public
Schools. The Natick Public Schools assumes the responsibility for complying with Child Online Privacy Protection Act (COPPA)
and the information that students submit. COPPA is a regulation that requires parental consent for the online collection of
information about users under 13. Students will not be using the email function of Google Apps until they are over 13.
I understand that the Natick Public Schools will provide Internet filtering software for the laptops while at school, or, if
my child is connecting to the Internet from home using a Natick Public Schools purchased/provided home laptop, which will
meet the CIPA guidelines.
I understand that it is the responsibility of the parent/guardian to manage and oversee the student’s use of email and
web resources at home.
SIGNED________________________________________
DATE:____________________________
PRINTED NAME_______________________________________________________________________________
NAME OF STUDENT_______________________________________HOMEROOM___________________________
9
VOLUNTARY EXTRACURRICULAR PROGRAM
PARENTAL/STUDENT CONSENT RELEASE FROM LIABILITY AND INDEMNITY AGREEMENT
We, the undersigned parents/guardians/legal representatives of ___________________________, a minor,
(Student’s name)
do hereby consent to his/her participation in Natick Public Schools’ voluntary extracurricular program(s), on behalf of
our heirs, our agents and our representatives and on behalf of____________________________
(Student’s name)
do forever release, acquit, discharge and covenant to hold harmless, the Town of Natick, and its successors, boards,
commissions, committees, officers, employees, servants, agents and representatives, of and from and against any and all
claims, demands, actions, causes of action, charges, lawsuits, loss of services, compensation, costs, including without
limitation attorney’s fees, damages and/or liability of any kind, in any way arising out of or resulting from, directly or
indirectly, all known or unknown personal injuries or property damage or death, which we may now have or hereafter
have as the parents/guardians/legal representatives of said minor, as well as any and all claims, demands, actions, causes
of action, charges, lawsuits, loss of services, compensation, costs, including without limitation attorney’s fees, damages
and/or liability of any kind, which said minor has or hereafter may acquire, either before or after he/she has reached
his/her age of majority, in any way arising out of or resulting from, directly or indirectly, his/her participation in Natick
Public Schools’ voluntary extracurricular programs.
FURTHERMORE, we, as parents/guardians/legal representatives of said minor, agree to indemnify and hold harmless the
Town of Natick, and its boards, commissions, committees, officers, employees, servants, agents and representatives,
(hereinafter “Natick and its personnel”) against any and all claims for damages, compensation or otherwise on the part of
said minor growing out of or resulting from injury to said minor in connection with , directly or indirectly, said minor’s
participation in Natick Public Schools’ voluntary extracurricular programs. We, further agree to indemnify, hold
harmless, reimburse and make good “Natick and its personnel”, for any judgments, costs, including without limitation
attorney’s fees, expenses, charges and damages of any kind which Natick and/or its personnel are required to pay as a
result of any act or omission of said minor or any parent, guardian or legal representative of said minor with respect to
his/her participation or Natick Public Schools voluntary extracurricular program.
We give permission for our son/daughter to participate in the program at ____________School for the _________ school
year. We have read the rules and regulations contained in the Student Handbook, including the Anti-Hazing law and
discipline code.
Both we and our son/daughter agree to abide by these regulations.
___________________________________________ _______________________________________
(Signature of parent/guardian/representative)
(Date)
___________________________________________ _______________________________________
(Signature of student)
(Date)
Extracurricular Activity:_________________________________________________________________
10
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER, SUBCONTRACTOR, LICENSING,
AND HOUSING PURPOSES.
NATICK PUBLIC SCHOOLS is registered under the provisions of M.G.L.c.6, 172 to receive CORI for the purpose of screening
current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and
applicants for the rental or lease of housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental
or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby
acknowledge and provide permission to NATICK PUBLIC SCHOOLS to submit a CORI check for my information to the DCJIS. This
authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing
NATICK PUBLIC SCHOOLS with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: The NATICK PUBLIC SCHOOLS may conduct subsequent
CORI checks within one year of the date of this Form was signed by me provided, however, that NATICK PUBLIC SCHOOLS must
first provide me with written notice of this check.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2 of this
Acknowledgement Form is true and accurate.
Please check one:
 Employment: Applicant
position/school ______________________________________
 Employment: Current Employee
position/school ______________________________________
 Employment: Sub-contractor
company/type position_________________________________
 Volunteers/Interns: Applicant
school ______________________________________________
 Volunteers/Interns: Current
school ______________________________________________
Telephone #:_____________________________________ Email: ______________________________________
________________________________________________ _______________________________
Signature
Date
PLEASE NOTE: This form must be submitted with a photo ID.
11
NATICK PUBLIC SCHOOLS
13 East Central Street
Natick, MA 01760
CORI REQUEST FORM
_____________________________________________________________________________________
Last Name
First Name
Middle Name
Suffix
_____________________________________________________________________________________
Maiden Name (or other name(s) by which you have been known)
__________________________
Date of Birth
___________________________________________________
Place of Birth
Last Six Digits of Your Social Security Number (this is required information): XXX- ______-_________
Sex: _______
Height: _____ft. ____in.
Eye Color: ____________
Race: __________
Driver’s License or ID Number: ______________________________ State of Issue: _______________
____________________________________________
Mother’s Full Maiden Name
________________________________________
Father’s Full Name
Current and Former Addresses:
______________________________________________________________________________
Street Number and Name
City/Town
State
Zip
______________________________________________________________________________
Street Number and Name
City/Town
State
Zip
______________________________________________________________________________
The above information was verified by reviewing the following form(s) of government issued identification:
VERIFIED BY: ________________________________________________
Name of Verifying Employee (Print)
________________________________________________
Signature of Verifying Employee
11/27/2012
12
MIDDLE SCHOOL FAMILIES ONLY
COURSE SELECTION SHEET
Special Education / Accommodation Plans
Does this student have a current Individualized Educational Plan (IEP)?
 Yes
 No
Does this student have a current Section 504 Accommodation Plan?
 Yes
 No
STUDENTS ENTERING 5TH OR 6TH GRADE (Band or Chorus is required)
 Band
 Chorus
STUDENTS ENTERING 7TH OR 8TH GRADE
WORLD LANGUAGE (choose 1)
 Spanish
 French
 Chinese (grade 7 only)
French_____________ Spanish___________ (second choice if unable to place in 1st choice)
AND
ARTS (choose 1)




Band
Chorus
VAP (video, art, and performance)—WILSON ONLY
General Music—KENNEDY ONLY
Parent / Guardian Signature
13
Middle & High School Laptop Contract/Form
Please complete this form if making payment by check.
Student Name: ___________________________________________________________________________
School: ____________________________________________________________________________________
SIS#: ____________________________________________ Year of Graduation: ____________________
Checks should be made out to the Natick Public Schools. Please bring this signed form along with payment to the front office of your
school. Failure to pay the annual fee will restrict laptop use to in school only and the equipment may not be taken home.
By signing you are agreeing to all terms and conditions of the Natick Public Schools Laptop Program which can be found at:
http://www.natickps.org/departments/technology/laptopprogram/acceptableuse.cfm
Please keep in mind these policies change from time to time and updates will be posted to the above website.
Laptop Accidental Damage/Loss Policy
There is a tiered approach for repair and restitution:
Tier I – Minor wear and tear covered by annual laptop fee. No additional charge.
Tier II – Moderate claims or replacing parts i.e., broken DVD drive ($100).
Tier III – More expensive claim – i.e. spill damage, cracked screen, dropped laptop ($200).
Tier IV – Lost or stolen device. Cost will be for full value of the device.
Additional information for the Laptop Program including 1 to 1 Parent & Student Handbook can be found at:
http://natickps.org/districtinfo/forstudents/onetoone.cfm
All the equipment remains property of the Natick Public Schools and must be returned to the school district in the same manner it was
given, whenever requested and/or when you are no longer a student of the Natick Public Schools.
Student Signature
Date
Parent Signature
Date
NOTES: Office Staff Only
STUDENT I.D.#: _________________________ PAYMENT RECEIVED: NO: _______ YES: _______ CHECK #: ___________
14
Kindergarten Families Only
Kindergarten Registration
Student Information Summary
Child’s name: ___________________________________ D.O.B. __________________________
Family Background Please list members of the household residing with the child.
Legal Guardians (include relationship to student)
__________________________________
__________________________________
Siblings in birth order (names and ages)
__________________________________
(Please note the date of birth for any preschool-aged
__________________________________
siblings so that we may cross reference with our data base
__________________________________
to project future school enrollments)
Others in household and their relationship to student
__________________________________
Parents/siblings living elsewhere
__________________________________
__________________________________
__________________________________
Primary language spoken at home
__________________________________
Developmental History
This information will help us prepare for your child’s success in kindergarten.
To date, my child has met overall developmental milestones within age-expected ranges?
(i.e. talking, walking etc.)
Comments:
Y
N
Language
My child can understand and follow simple directions?
Y
N
S/he can express his/her needs using clear language?
Y
N
Someone unfamiliar to my child would be able to understand his/her speech?
Y
N
Y
N
Comments:
Motor
Can your child sufficiently walk, climb, run and/or grasp things safely?
15
If no, explain…
Social/behavioral
My child can engage in play with other children?
Y
N
S/he can engage in dramatic/imaginative play?
Y
N
S/he can express feelings or concerns in an age-appropriate manner?
Y
N
S/he can usually separate from me?
Y
N
S/he is inclined to adjust in new situations?
Y
N
S/he can handle frustration appropriately?
Y
N
My child can care for his/her toileting needs independently?
Y
N
S/he can zip, snap, tie clothing as needed?
Y
N
Y
N
Comments:
Self help:
Comments:
Preschool Experience
My child has had structured preschool experiences? (daycare, preschool)
For how long? ___________________Where? ___________________________________________________
If not, what opportunities has he/she had to be with small groups of children (5 or more)?
_________________________________________________________________________________________
What types of activities does he/she prefer to do alone, given free choice? ______________________________
________________________________________________________________________________________
Transition to Kindergarten
What do you think your child is looking forward to in kindergarten? ____________________________________
_________________________________________________________________________________________
How do you anticipate your child will make the transition to school? ___________________________________
_________________________________________________________________________________________
Release of Information
Child’s Name ___________________________________ Guardian Name______________________________
I give my consent for the staff of the Natick Public Schools to contact __________________________________
Nursery school teacher /daycare provider
for any information deemed pertinent to my child’s school success.
_____________________________________________
_______________________
Signature
Date
16
Notification of Rights Under FERPA (Family Educational
Rights and Privacy Act) and MA Student Records Regulations
& Directory Information Notice
Notification of Rights under FERPA
The Family Educational Rights and Privacy Act (FERPA) and Massachusetts Student Records Regulations affords parents and
students over 14 years (“eligible students”) certain rights with respect to the student’s education records. These rights are:
1.
The right to inspect and review the student’s education records. Access is generally provided within 10 days of the
request. State law sets forth specific procedures prior to the release of records to a non-custodial parent (M.G.L. c. 71
§34H).
Parents or eligible students should submit to the School principal (or appropriate school official) a written request that
identifies the record(s) they wish to inspect. The School principal will make arrangements for access and notify the
parent or eligible student of the time and place where the records may be inspected. Upon request, copies of any
information contained in the student record will be furnished to the parent or eligible student, subject to a reasonable
copying fee.
2. The right to request the amendment of the student’s education records that the parent or eligible student believes is
inaccurate, misleading, or otherwise in violation of the student’s privacy rights under FERPA or state law.
Parents or eligible students who wish to ask the School to amend a record should write the School principal (or
appropriate school official), clearly identify the part of the record they want changed, and specify why it should be
amended. If the School decides not to amend the record as requested by the parent or eligible student, the School will
notify the parent or eligible student of the decision and advise them of their right to a hearing regarding the request
for amendment. Additional information regarding the hearing procedures will be provided to the parent or eligible
student when notified of the right to a hearing.
3. The right to consent to disclosures of personally identifiable information contained in the student’s education records,
except to the extent that FERPA and state law authorize disclosure without consent.
One exception, which permits disclosure without consent, is disclosure to school officials with legitimate educational
interests. A school official is a person employed the School as an administrator, supervisor, instructor, or support staff
member (including health or medical staff and law enforcement unit personnel); a person serving on the School Board;
a person or company with whom the School has contracted to perform a special task (such as an attorney, auditor,
medical consultant, or therapist); or a parent or student serving on an official committee, such as a disciplinary or
grievance committee, or assisting another school official in performing his or her tasks. A school official has a
legitimate educational interest if the official needs to review an education record in order to fulfill his or her
professional responsibility. Upon request, the School discloses education records without consent to officials of
another school district in which a student seeks or intends to enroll.
4. The right to file a complaint with the U.S. Department of Education concerning alleged failures by the school district to
comply with these legal requirements.
Complaints may be filed with the Massachusetts Department of Elementary and Secondary Education (DESE), 75 Pleasant
St., Malden, MA 02148 and/or the Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Ave., SW,
Washington, DC 20202-5901.
17
FERPA Directory Information Notice
The Family Educational Rights and Privacy Act (FERA), a Federal law, requires that Natick Public Schools, with certain
exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s
education records. However, the Natick Public Schools, may disclose appropriately designated “directory information”
without written consent, unless you have advised the District to the contrary in accordance with District procedures. The
primary purpose of directory information is to allow the Natick Public Schools to include this type of information from your
child’s education records in certain school publications. Examples include:





A playbill, showing your student’s role in a drama production;
The annual yearbook;
Honor roll or other recognition lists;
Graduation programs; and
Sports activity sheets, such as for wrestling, showing weight and height of team members
Directory information, which is information that is generally not considered harmful or an invasion of privacy if released,
can also be disclosed to outside organizations without a parent’s prior written consent. Outside organizations include, but
are not limited to, companies that manufacture class rings or publish yearbooks. In addition, two federal laws require local
educational agencies (LEA’s) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to
provide military recruiters, upon request, with three directory information categories-names, addresses and telephone
listings-unless parents have advised the LEA that they do not want their student’s information disclosed without their prior
written consent.
If you do not want the Natick Public Schools to disclose directory information from your child’s education records without
your prior written consent, you must notify your school principal in writing by (October 1 of the school year or, if after
October 1, 30 days after your child officially starts school. The Natick Public Schools have designated the following
information as directory information:













Student’s name
Participation in officially recognized activities and sports
Address
Telephone listing
Weight and height of members of athletic teams
Electronic mail address
Photograph and video image
Degrees, honors, and awards received
Date and place of birth
Major field of study
Dates of attendance
Grade level
Post-high school plans
18
How to Sign Up for District and School Email Notices
(Blasts)—Our District’s Primary Communication Tool
To access our school web page, simply go to www.natickps.org
To receive our Email blasts, please join our Email list located under the Quick Links Menu on the left side of the home page.
You may easily navigate around the site.
Go to your child’s particular school and:








Choose to view our daily announcements to hear all the same information that your child is hearing during home room
period.
Click on the picture of the Backpack and see all the flyers that would normally go home in paper form. It is updated
and added to throughout the week and is also archived each week so you can check out what you may have missed.
You can access our calendar tab to see upcoming events like concerts, theater productions, PTO meetings, etc.
Once on your child’s school website,
o At the top you will see a Program bar (preschool) Teams bar (middle school), Academic bar (high school) or
Grade Level bar (elementary school) that allows you to access your child’s team/teacher/program information
regarding class work, home work and specific academic information.
Click on the Contact Us tab to email your child’s teacher directly.
You will find lots of forms posted to our sites, like field trip forms, permission slips, business office forms such as free
and reduced lunch and bus forms, that you can easily download to fill out and send in.
Find the UniBall online payment button and a wealth of other resources under the “Parent” tab on the mid-right hand
side of all school web pages.
There is much more information on our site that is just a click away.
Our goal is to make access to all pertinent information at your fingertips. And as always, feel free to call the main office of any
school with questions you cannot find answered on our site.
19
NATICK PUBLIC SCHOOLS
RESIDENCY AFFIDAVIT/PROOF OF RESIDENCY
LANDLORD/SHARED TENANCIES
Instructions: Any applicant for the Natick Public Schools who cannot produce a property deed or lease must ask the
owner or lessee of the property where the applicant lives to complete and sign this legal affidavit. It is the
responsibility of the applicant (not the person who completes this affidavit) to attach a record of recent rent
payment unless this affidavit affirms in Item #3 below that the tenancy does not require payment of rent.
AFFIDAVIT
My name is _____________________________________and I hereby depose and certify as follows: (Please
complete all three items and sign below.)
1. I am the owner/lessee of property located at
_______________________________________________________in the town of Natick.
2. (Parent or guardian name)____________________________________________________,
who is the parent or legal guardian of (child’s/childrens’ name)_______________________________,
leases or subleases this property as their principal residence from me, without a written lease, in a tenancy at
will, from month to month.
3. PLEASE CHECK ONE:
I have received within the last thirty (30) days rental payment for the lease or sublease of these premises.
OR:
Alternatively, I hereby state that the party named above resides with me at the address above with no
payment of rent.
Signed under the pains and penalties of perjury this _______day of_____________20____.
_______________________________________________________
Signature
Print Name:_________________________________________________________________
Print Address:_______________________________________________________________
Phone:_____________________________________________________________________
The information contained in this legal affidavit is subject to verification by a residency investigator.
20
OPTIONAL RESIDENCY FORMS FOR NATICK FAMILIES
NOTE: These forms are not needed if you have a lease with all family members’ names on it, a purchase and
sale or other forms of residency proof.
Affidavit of Residency WITH Written Documentation Provided
________________________________________, a
prospective student in the Natick Public Schools, will be
residing with me at my address, ____________________________________ in Natick, MA, for the
school year _______. My relationship to the student is as his/her ____________________________.
Furthermore, I attest to the following statements:
1. The above named student is residing with me as the student’s Parent(s) or Guardian(s).
2. This address will become the student’s primary residency and he/she will live
at this address in Natick.
3. I agree to notify the Natick Public Schools immediately should the above named
student change residency.
4. I attach proof of residency with the following document:
___ Lease or Rental Agreement
___ Deed
___ Tax Bill
___ Electric Bill
___ Other___________________________________
Signed under pain and penalty of perjury this _______ day of ____________ in the year _______.
____________________________________________________
Signature
____________________________________________________
Please Print Name
____________________________________________________
Address
____________________________________________________
Home Phone
21
OPTIONAL RESIDENCY FORMS FOR NATICK FAMILIES
NOTE: These forms are not needed if you have a lease with all family members’ names on it, a purchase and
sale or other forms of residency proof.
Affidavit of Residency WITHOUT Written Documentation
________________________________________, a
prospective student in the Natick Public Schools, will be
residing with me at my address, ____________________________________ in Natick, MA, for the school
year _____________. My relationship to the student is as his/her ____________________________.
Furthermore, I attest to the following statements:
1. The above named student is residing with me as the student’s Parent(s) or Guardian(s).
2. This address will become the student’s primary residency and he/she will live
at this address in Natick.
3. I agree to notify the Natick Public Schools immediately should the above named
student change residency.
4. I am unable to produce home ownership or tenancy documentation.
Signed under pain and penalty of perjury this _______ day of ____________ in the year _______.
____________________________________________________
Signature
____________________________________________________
Please print name
____________________________________________________
Address
____________________________________________________
Home Phone
22
OPTIONAL RESIDENCY FORMS FOR NATICK FAMILIES
NOTE: These forms are not needed if you have a lease with all family members’ names on it, a purchase and
sale or other forms of residency proof.
Affidavit of Residency, Residing with Person OTHER THAN Parent/Guardian
________________________________________, a
prospective student in the Natick Public Schools, will be
residing with me at my address, ____________________________________ in Natick, MA, for the school
year _____________. My relationship to the student is as his/her ____________________________.
Furthermore, I attest to the following statements:
2. The above named student is residing with me with the full knowledge and permission
of his/her parent(s)/guardian(s).
3. The above named student is not residing with me for the sole reason of attending
Natick Public Schools.
3. My address will become the student’s primary residency and he/she will live
at this address in Natick the majority of days each week throughout the entire year.
4. I will serve as the primary contact person regarding the above named student’s
attendance and have the requisite authority from his/her parent(s)/guardians) to
make decisions regarding:
a. the above named student’s attendance at school, and
b. medical treatment for the above named student.
5. I agree to notify the Natick Public Schools immediately should the above named
student change residency.
Signed under pain and penalty of perjury this _______ day of ____________ in the year _______.
____________________________________________________
Signature
____________________________________________________
Please Print Name
____________________________________________________
Address
____________________________________________________
Home Phone
23