Binghamton City School District
Providing a rich environment for quality learning
Office of Attendance & Pupil Services
98 Oak Street
Binghamton, New York 13905
607.762.8114
REGISTERING SPECIAL NEEDS STUDENTS FOR SCHOOL
A Checklist of Things to Bring with You
Welcome to Binghamton Area and our City School District! We look forward to working with you and
your children during the school year.
Before you come to 98 Oak Street to register your child(ren) for school, please consider this:
1.
Before leaving your former district, please contact them and get copies of the documents listed
below. Bringing that information with you when you register your child(ren) can help us get them
placed into school in a more timely fashion.
2.
You should register your child(ren) as soon as possible. If you move in the summer, please do not
wait for September to register them. We get overcrowded at that time, and waiting may cause your
child(ren) to start later than everyone else.
Note: We cannot finalize registration for a child without these important documents. We suggest
that you obtain copies of these documents from the former school to bring with you.
____
____
____
____
____
____
____
Student’s Birth Certificate
Two (2) Proofs of Residency – Lease, DSS Statement, Utility bill, or other acceptable proof
Immunization Records
Copy of the most recent IEP or 504 Plan (if applicable)
Parent/Guardian Picture Identification
Custody Papers indicating residential custody (if applicable)
School Records/Transcript or Final/Most Recent Report Card or Withdrawal Grades
You will be asked to sign a release form so we can fax a request for records to the former school if you are
not able to obtain copies to bring with you at the time of registration. We will make every effort to
communicate with the former school but the Binghamton City School District cannot be held responsible for
the former’s school failure to respond in a timely manner.
Your child may not be allowed to attend school until the above records are received.
(kdy11/14/13)
Binghamton City School District
Office of Attendance & Pupil Services
98 Oak Street
Binghamton, New York 13905
607.762.8114
Release of Records
Date:
To:
Dear Guidance or Records Office:
,
(Student Name:
First
Middle
Last)
School in the Binghamton City School District for the







has enrolled in
(MM
/
School Year. We are Requesting the following:
Complete transcript indicating credits and numerical grades
received.
Key to grading system (i.e. A = 92, A- = 89-91, etc)
Disciplinary Record
Withdrawal grades and most recent report card
Test Scores / Counselors Test Scores
Individual Education Plans (IEP), 504 Plan
Social History
Grade in
DD / YYYY)

Birth Certificate






Health Records including shot records/Immunizations
Minutes of Completed Science Labs
Custody Papers
FBA, BIP
Vocational Assessment
Psychological Evaluation
Fax records to Pupil Services at (607)762-8142. Thank you!
THE ENROLLMENT DATE SHOULD BE 2 DAYS AFTER WE RECEIVE RECORDS
Parent/Guardian Signature:
Date:
According to the Final Regulation – Family Education Rights and Privacy Act (Buckley Amendment) dated 6/17/76, it is no longer necessary to obtain written consent to release records.
It states those school officials, including teachers within the educational institution and officials of other schools in school systems in which the student may intend to enroll, may receive a
student record without a written consent for such a release
BINGHAMTON CITY SCHOOL DISTRICT
REGISTRATION FORM
*PLEASE PRINT*
*PLEASE PRINT*
OFFICE USE ONLY
Student ID:
Building:
Grade Assigned:
Entry Date:
Transportation:
Yes
School Year:
Teacher/Counselor:
No
Hrm:
Notes:
Student Name:
Suffix:
(First
Middle
Sex:
Last)
Date of Birth:
BIRTHPLACE:
MM
/
DD /
YYYY
(City,
Citizenship:
State,
Country)
Country of Birth:
Date entered US:
MM
Ethnicity: Is the student Hispanic, Latino or of Spanish origin?
Race: (Please check all that apply)
Yes
/
African American
Yes
Ever attend a Binghamton School:
American Indian/Alaskan Native
Asian
White
No
Yes
YYYY
No
Native Hawaiian/Pacific Islander
Ever attend a NYS School:
DD /
If yes, indicate School/Year:
No
If yes, indicate School/Year:
Name of Last School Attended:
Address:
City:
State:
Grade:
Zip:
Date Left:
MM
Support Services:
IEP:
Yes
If yes, check all that apply:
No
504:
Yes
No
Extra Help:
Yes
DD
No
Smaller (self-contained) Classroom Setting
Speech
AIS
RTI
Pull-out period for academic support
Resource Room
OT
PT
GUARDIAN INFORMATION
Name:
Suffix:
(First
Middle
Street:
Last)
Apt #:
Home Phone:
Cell Phone:
Relationship to
Student:
Guardian
Email:
City:
State:
Zip:
Work Phone:
Place of
Employment:
Name:
Suffix:
(First
Street:
Home Phone:
Relationship to
Student:
Middle
YYYY
Last)
Apt #:
City:
State:
Cell Phone:
Work Phone:
Guardian
Email:
If student is not living with both parents, who has legal custody?
Place of
Employment:
Mother
Father
Other
Zip:
Any custody documents?
Yes
No
Provide any documentation regarding custody.
*****PROVIDE DOCUMENTS*****
****Those designated below are authorized to pick up student from school in an emergency****
EMERGENCY CONTACT INFORMATION
Name:
****Continue ****
Suffix:
Street:
Apt #:
Home Phone:
Cell Phone:
City:
State:
Zip:
Work Phone:
Relationship to Student:
Name:
Suffix:
(First
Middle
Last)
Street:
Apt #:
Home Phone:
Cell Phone:
City:
State:
Zip:
Work Phone
Relationship to Student:
Day Care Provider:
Address:
Phone:
Other Children in Family:
Name:
School:
Sex:
DOB:
At residence:
Name:
School:
Sex:
DOB:
At residence:
Name:
School:
Sex:
DOB:
At residence:
Name:
School:
Sex:
DOB:
At residence:
Other Persons Living in Residence:
Name:
Relationship:
Name:
Relationship:
Where is the student currently living? (Please check one box)
1.
In permanent housing
5.
In a shelter, FEMA trailer, or waiting for foster care (Please
describe) __
________________________________
2.
With another family or other person because of loss
of housing or as a result of economic hardship
(same as “doubled up”)
6.
Other temporary living situation
3.
In a hotel/motel
7.
In a car, park, bus, train, campsite, abandoned building, etc.
4.
I have moved in the past 3 years to seek work as a
paid laborer in farming
If you checked 2-7, are you also an unaccompanied youth?
(Unaccompanied means that you are not currently living with parent/guardian)
Date moved into temporary
housing:
Yes
No
By signing below, I represent that the information I have provided in this declaration is true and correct. I understand that false or misleading
information related to this registration my result in the removal of my student, as well as other legal sanctions.
Signature of Parent/Guardian:
Date:
BINGHAMTON CITY SCHOOL DISTRICT
HOME LANGUAGE QUESTIONNAIRE
*PLEASE PRINT*
*PLEASE PRINT*
Student Name:
(First
Middle
Last)
Country of Birth:
Country of Origin:
Date Entered USA:
Years in the US:
Date of Entry to US School:
Check all boxes (below) that apply:
What language(s) is spoken in the student’s home or residence?
English
Other
Specify:
What language(s) is spoken most of the time to the student in home
or residence?
English
Other
Specify:
What language(s) does the student understand?
English
Other
Specify:
What language(s) does the student speak?
English
Other
Specify:
What language(s) does the student read?
English
Other
Specify:
What language(s) does the student write?
English
Other
Specify:
In your opinion, how well does the student understand, speak, read and write English:
Understands English:
Very Well
Only a little
Not at all
Speaks English:
Very Well
Only a little
Not at all
Reads English:
Very Well
Only a little
Not at all
Writes English:
Very Well
Only a little
Not at all
Signature of Parent/Guardian:
Date:
OFFICE USE ONLY
Student ID:
Building:
Grade:
Student Name:
Determination:
Possible LEP
English Proficiency Level:
Signature of School Official:
English Proficient
Date of Informal Interview:
Date of LAB-r:
Date:
Binghamton City School District
Christopher Columbus School
164 Hawley Street
PO Box 2126
Binghamton, NY 13902-2126
(607) 762-8100
Fax: (607) 762-8112
July 17, 2013
The Binghamton City School District will be providing a web-based Parent Home Access system allowing parents/guardians
to view important information about their student(s).
Parents/Guardians who have internet access will be able to utilize the system by filling out the “Parent Home Access
Registration Request” form, found on the back of this letter, and returning it to the address listed on the bottom of the form
or to the Principal’s office in your student’s school of attendance. Only parents/guardians who are definitively registered as
a student’s guardian in the district’s student registration system will be allowed access.
With the “Parent Home Access Registration Request”:
1. Your user ID will be your email address.
2. A password will be emailed to you and you may change your password at any time by following on screen
instructions. We suggest the password have at least one capital letter and one number.
3. Return the form.
The BCSD website (www.binghamtonschools.org) will be the portal by which you will access the system.
If you have any questions about the Parent Home Access System, please email the BCSD Information Services Department
at isd@binghamtonschools.org
Sincerely,
Michael Purdy
Chief Information Officer/Director of Information Services
Binghamton City School District
BINGHAMTON CITY SCHOOL DISTRICT
PARENT HOME ACCESS REGISTRATION REQUEST
Parent/Guardian Name:
Error! Reference source not found.
Student 1 Name:
Date of Birth:
Student 2 Name:
Date of Birth:
Student 3 Name:
Date of Birth:
Student 4 Name:
Date of Birth:
Student 5 Name:
Date of Birth:
Student 6 Name:
Date of Birth:
*************ALL SECTIONS BELOW MUST BE FILLED OUT *************
Email Address will be
your User ID
(Print clearly your email address)
Password
(Please print clearly your email address a second time)
(your password will be emailed to you)
Parent/Guardian
Signature:
7151
Subject: Use of computers and Information Technology
BINGHAMTON CITY SCHOOL DISTRICT NETWORK AND INTERNET ACCESS CONSENT AND WAIVER
The following form must be read and signed by you and your parent or legal guardian.
By signing this Consent and Waiver form,
and my parent(s) or guardian(s) agree to abide by the following restrictions. I have discussed these rights and responsibilities with my parent(s) or
guardian(s).
Further, my parent(s) or guardian(s) and I have been advised that the District does not have control of the information on the Internet, although it
attempts to provide prudent and available barriers. Other sites accessible via the Internet may contain material that is illegal, defamatory, inaccurate
or potentially offensive to some people. While the Binghamton City School District’s intent is to make Internet access available to further its
educational goals and objectives, account holders will have the ability to access other materials as well.
The District believes that the benefits to educators and students from access to the Internet, in the form of information resources and opportunities
for collaboration far exceed any disadvantages of access. Ultimately, the parent(s) and guardian(s) of minors are responsible for setting and
conveying the standards that their student should follow. To that end, the District supports and respects each family’s right to decide whether or not
to apply for Binghamton City School District network access.
The student and his/her parent(s) or guardian(s) must understand that student access to the Binghamton City School District network exists to
support the District’s educational responsibilities and mission statement. The specific conditions and services that are offered will change from time
to time. In addition, the Binghamton City School District makes no warranties with respect to the Binghamton City School District network service,
and it specifically assumes no responsibilities for:
A.
B.
C.
D.
The content of any advice or information received by a student from a source outside of the District, or any costs or charges
incurred as a result of seeing or accepting such advice;
Any cost, liability or damages caused by the way the student chooses to use his/her District network access;
Any consequences of service interruptions or changes, even if these disruptions arise from circumstances under the control of
the District;
While the Binghamton City School District supports the privacy of electronic mail, students must assume that this cannot be
guaranteed.
By signing this form I agree to the following terms:
1.
My use of the Binghamton City School District network must be consistent with the Binghamton City School District’s primary
goals.
2.
I will not use the Binghamton City School District network for illegal purposes of any kind.
3.
I will not use the Binghamton City School District network to transmit threatening, obscene or harassing materials. The District
will not be held responsible if I participate in such activities.
4.
I will not use the Binghamton City School District network to interfere with or disrupt network users, services or equipment.
Disruptions include, but are not limited to, distribution of unsolicited advertising, propagation of computer worms or viruses, and
using the network to make unauthorized entry to any other machine accessible via the network. I will print only to my local
printer or to the printer designated by my instructor.
5.
It is assumed that information and resources accessible via the Binghamton City School District network are private to the
individuals and organizations, which own or hold rights to those resources and information unless specifically stated otherwise by
the owners or holders of rights. Therefore, I will not use the Binghamton City School District network to access information or
resources unless the owners or holders of rights to those resources or information have granted permission.
Continued
7151
Subject: Use of computers and Information Technology
6.
If I breach the Policy, Agreement, or applicable rules and procedures I understand I will lose all network privileges and be subject
to discipline.
Student Name:
Grade:
(Please Print)
Student Signature:
Date:
I understand that my child is expected to use good judgment and follow the attached rules in using electronic technology. Should my child breach
the Policy, Agreement, or applicable rules and procedures I understand my child will lose all network privileges and be subject to discipline.
Parent/Guardian Name:
Error! Reference source not found.
(Please Print)
Signature:
Date:
BINGHAMTON CITY SCHOOL DISTRICT
Special Services
98 Oak Street
Binghamton, NY 13905
(607)762-8136
Parent Consent Form for Initial Evaluative Testing of
OFFICE USE ONLY
Student’s Name:
School:
Student ID:
Please check the appropriate response in regard to the request of the Committee on Special Education to obtain evaluative information
concerning your child:
I voluntarily give my consent to do the initial evaluations that are described in the enclosed notice. I understand that I may reconsider
my consent to the initial evaluation at any time before its completion by writing to the chairperson of the Committee on Special
Education. (I have been advised of what records concerning my child will be released, if any, and to whom they will be released).
I do not give my consent to do the evaluations described in the enclosed notice, but I do wish that an informal conference be scheduled
with the Committee or with designated professionals most familiar with the proposed evaluation, the person who referred my child and
counsel or advisor of my choice if I so desire.
I do not give my consent to do the evaluations described in the enclosed notice, and I do not wish that an informal conference be
scheduled with the Committee or with designated professionals most familiar with the proposed evaluation.
In the event that you do not consent or do not request or attend an informal conference within thirty days after receipt of a referral, the Board of
Education must initiate an impartial hearing to determine whether the evaluation shall be conducted without your consent. Not that during the
pendency of any proceedings conducted regarding not giving consent for the evaluations, unless the Commissioner of local Board of Education
and the parents or legal guardian otherwise agree, the child shall not be evaluated and shall remain in the current educational placement. If
applying for initial admission to public school, the child shall be placed in the public school program until all such proceedings have been
completed.
Parent or Legal Guardian Signature:
Date:
BINGHAMTON CITY SCHOOL DISTRICT
Special Services
98 Oak Street
Binghamton, NY 13905
(607)762-8136
OFFICE USE ONLY
Student Name:
Student DOB:
School:
Student ID:
Please check the appropriate responses in regard to the placement recommendations of the committee
on Special Education concerning your child:
I voluntarily give my consent to the placement described in the enclosed notice. I
understand that I can reconsider my consent for initial placement at any time
before the Board of Education approval. I have been advised of all the information
relevant to the recommended placement and of what records concerning my child
will be released. If any, and to whom they will be released.
I do not give my consent to the placement described in the enclosed notice.
Parent or Guardian Signature:
SPSV-15
Date:
BINGHAMTON CITY SCHOOL DISTRICT
Special Services
98 Oak Street
Binghamton, NY 13905
Parent Consent Form for Section 504 Accommodations / Services
(607)762-8136
OFFICE USE ONLY
Student’s Name:
School:
Student ID:
Please check the appropriate box in response to the Section 504 Team’s proposed accommodations and / or services, as described in the
enclosed 504 Accommodations Plan:
I voluntarily give consent for the 504 accommodations and / or services described in the enclosed
Section 504 Accommodation Plan.
I do not give consent for the 504 accommodations and / or services described in the enclosed
Section 504 Accommodation plan and I wish that an informal conference be scheduled with the Section
504 Team, the person who referred my child, and counsel or advisor of my choice, if I so desire.
Signature of Parent/Guardian:
Date:
BINGHAMTON CITY SCHOOL DISTRICT
Special Services
98 Oak Street
Binghamton, NY 13905
(607)762-8136
Parent Consent Form for Section 504 Evaluation
OFFICE USE ONLY
Student’s Name:
School:
Student ID:
Please check the appropriate response in regard to the request of the Section 504 Team to obtain evaluative information concerning your child:
I voluntarily give my consent to do the initial evaluations that are described in the enclosed notice.
I do not give my consent to do the evaluations described in the enclosed notice, but I wish that an
informal conference be scheduled with the Section 504 Team, the person who referred my child, and
counsel or advisor of my choice, if I so desire.
Signature of Parent/Guardian:
Date:
BINGHAMTON CITY SCHOOL DISTRICT
Special Services
98 Oak Street
Binghamton, NY 13905
(607)762-8136
Dear Parent/Guardian of:
This is to ask your permission (consent) to bill Medicaid for Medicaid reimbursable services that are on your child’s
individualized education program (IEP) and to request prescriptions for occupational therapy (OT) and or physical therapy
(PT) services from your child’s medical provider. Schools in New York State routinely access Medicaid funding to help
meet costs of providing special education services. In order to do so in some cases it is necessary to obtain a
prescription or physician’s order for OT and PT services as stated on the IEP. Please read and confirm the following
information:
I,
Error! Reference
found.
source
not
as the parent/guardian of
(Print Parent/Guardian Name)
(Print Student’s Full Name)
Give permission for the school district / municipality to use Medicaid to pay for special education services rendered on
behalf of my child for all Medicaid eligible
services listed on my child’s IEP dated:
.
I also consent to communications with and requisition prescriptions or physician’s order from my child’s medical provider
for OT and/or PT services as stated on the IEP.
I understand that the use of Medicaid insurance for special education services will not decrease the available lifetime
coverage, increase premiums or lead to the discontinuation of benefits, result in my family paying for other services
required for my child outside of school that would otherwise be covered by the Medicaid program or otherwise diminish
my family’s insured benefits under the Medicaid program and that I will not incur an out-of-pocket expense such as
payment of a deductible or co-pay amount.
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my
child’s entitlement to a free appropriate public education (FAPE) is in no way dependent on my granting consent and that,
regardless of my decision to provide this consent; all the required services on my child’s IEP will be provided to my child
at no cost to me.
Parent/Guardian Signature:
Date:
BINGHAMTON CITY SCHOOL DISTRICT
Special Services
98 Oak Street
Binghamton, NY 13905
(607)762-8136
SOCIAL HISTORY
Confidential
Student Name:
Address:
Date:
Error! Reference source not found.
School
Date of Birth:
Grade:
Phone:
Teacher:
Error! Reference source
not found.
Age:
REASON FOR REFERRAL
A.
Home Information
Child lives with:
Mother:
Age:
Street:
City:
Father:
Age:
Street:
State:
Zip:
City
Phone:
Phone:
Marital Status:
Marital Status:
Education:
Education:
Occupation:
Occupation:
State
Other Children in Family:
Name:
Age:
Placement:
Name:
Age:
Placement:
Name:
Age:
Placement:
Name:
Age:
Placement:
Other Persons Living in Residence:
Name:
Relationship:
Name:
Relationship:
What language is spoken in your home:
Please list any agencies that you have been involved with such as Mental Health Clinic, Catholic Charities, etc.
Agency:
Contact Person:
Agency:
Contact Person:
Agency:
Contact Person:
Zip
B.
Medical and Developmental History
Mother’s age at onset of this pregnancy?
Birth Weight?
Child’s rank in family
Cesarean Section?
Significant factors in pregnancy and infancy (condition upon delivery, diet problems, respiratory problems, RH incompatibility, illness, etc.)
As your child grew up did your child experience any of the following?
Illness:
Accidents:
Surgery:
Please estimate the age at which your child:
Walked
Was Toilet Trained
Talked
Present Physician
Last Exam
List any medication that your child is taking and explain why it is taken:
Does your child need any special devices for treatment or daily living (glasses, hearing aid, braces, catheter, aspirator, etc)?
Has your child ever experienced problems in any of these areas? If so, please briefly describe the circumstances.
Lack of energy or overtired
Feeding or Diet Problems
Sleeping problems/nightmares
Head banging or rocking
Tantrums
Destructiveness
Headaches
Loss of consciousness
Convulsions
Ears
Eyes
Coordination
Fears
Anxiety problems
Hyperactivity
Other
Does your child have a learning problem in school?
C.
Social History
How would you describe your child’s personality and self-image?
What is your child’s relationship with:
parent(s)
other adults
peers
brothers and sisters
Who administers discipline and what type of discipline is used?
Describe your child’s responsibilities with the family, his/her:
interests and play activities
chores
interests
D.
Educational History
Please list schools attended and any grades repeated:
Day Care
Age:
Pre School
Age
K-5
Age Entered
Middle School
Age Entered
High School
Age Entered
How would you describe your child’s relationship with teachers and classmates?
How would you describe your child’s difficulties in school (e.g., poor health, excessive absences, frequent change of school(s)?
What would like the school to do?
Comments:
Parent or Guardian’s Signature:
Date
Interviewer (if present)
Date:
BINGHAMTON CITY SCHOOL DISTRICT
CHILD DEVELOPMENT FORM
(Kindergarten Only)
STUDENT NAME:
DATE OF BIRTH:
(First, Middle, Last)
ELEMENTARY SCHOOL:
Horace Mann
Calvin Coolidge
Benjamin Franklin
Thomas Jefferson
MacArthur
Theodore Roosevelt
Woodrow Wilson
Please indicate (below) each of the child care programs or school programs your child has attended:
Birth to Age Three
In-home day-care with family member
or neighbor
In-home day-care with certified day care
provider
Campus Preschool & Early Childhood
Center
STC
All My Children
Magic years Child Care and Learning
Center
B.C. Center at BCC
Family Enrichment Network
BOCES Daycare Center
Day Nursery Association
YWCA Kids Korner
Jewish Community Center
PACT Program (BCSD)
WiseKids (Evenstart)
Other:
Age Three
In-home day-care with family member
or neighbor
In-home day-care with family member or
neighbor
Campus Preschool & Early Childhood
Center
Binghamton City School District pre-K
St. Thomas Aquinas Nursery School
Magic years Child Care and Learning
Center
Little World Preschool
Riverside Drive Nursery School
YWCA Kids Corner
St. John the Evangelist
Jewish Community Center
Y’S Kids Child Care Center
B.C. Center at BCC
All My Children
PACT Program (BCSD)
BOCES Daycare Center
BOCES Learn and Grow
Other:
BOCES Nursery School
Family Enrichment Network
Age Four
In-home day-care with family member
or neighbor
In-home day-care with family member or
neighbor
Campus Preschool & Early Childhood
Center
Binghamton City School District pre-K
St. Thomas Aquinas Nursery School
Magic years Child Care and Learning
Center
Little World Preschool
Riverside Drive Nursery School
YWCA Kids Corner
St. John the Evangelist
Jewish Community Center
Y’S Kids Child Care Center
B.C. Center at BCC
All My Children
PACT Program (BCSD)
BOCES Daycare Center
BOCES Learn and Grow
Other:
BOCES Nursery School
Family Enrichment Network
****Continue****
(Kindergarten Only)
Please answer the following informational questions regarding your child’s development.
Can your child -
feed him or herself using a spoon and/or a fork?
Yes
No
wash and dry his or her own hands?
Yes
No
help with dressing or dress with little assistance?
Yes
No
Speak so that he or she can be understood by others?
Yes
No
Yes
No
eating?
Yes
No
sleeping?
Yes
No
toilet trained during the day?
Yes
No
in need of help with toileting?
Yes
No
play with blocks, boxes, cups or other construction toys without help?
Yes
No
use crayons and/or marker to scribble or draw?
Yes
No
listen to stories being read?
Yes
No
turn pages of a book and look at pictures?
Yes
No
recall stories or events?
Yes
No
enjoy playing alone?
Yes
No
talk with your friends/relatives who come to visit?
Yes
No
follow one-step directions?
Yes
No
follow two-step directions?
Yes
No
have opportunities to play with other children?
Yes
No
use words rather than physical actions to settle arguments with others?
Yes
No
over-react or have temper tantrums?
Yes
No
highly active?
Yes
No
very quiet?
Yes
No
Does your child sit very close to the TV?
Yes
No
Does your child turn up the volume on the TV very high?
Yes
No
Has your child ever been referred to early intervention services? (optional)
Yes
No
Does your child have difficulty separating from you?
Do you have any concerns about your child’s -
Is your child -
Does your child -
Is your child -
Are there other things you would like to tell us about your child?
BINGHAMTON CITY SCHOOL DISTRICT
EMERGENCY CARE/CONTACT INFORMATION
In case of an emergency, the school staff will contact 911. Every attempt will be
made to contact a parent, a guardian or a designated contact.
*PLEASE PRINT*
I
N
F
O
Student Name:
Date of Birth:
Gender:
Male
School:
Female
Grade:
Teacher/Counselor:
PARENT/GUARDIAN CONTACT INFORMATION
Any parent with whom the child resides has the right to make decisions concerning the child in the event of an emergency and to pick up the child from
school. A non-custodial parent has the right to be listed as an emergency contact unless a court order or other legal document stating otherwise has been
presented to the school.
Parent / Guardian Name:
Home Phone:
(First
Middle
Last)
Street:
City:
State:
Relationship to Student:
Error! Reference source
not found.
Error!
Refere
nce
source
not
found.
Apt #:
Error!
Reference
source not
found.
Work Phone:
Zip:
Error!
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source not
found.
Cell Phone:
Email:
Place of Employment:
Language:
Resides with:
Parent / Guardian Name:
Middle
No
Last)
Street:
State:
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not found.
Email:
Error!
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nce
source
not
found.
Apt #:
Error!
Reference
source not
found.
Zip:
Error!
Reference
source not
found.
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source not found.
Language:
Work Phone:
First Name:
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Relationship to Student:
Yes
Home Phone:
(First
City:
Last Name:
S
T
U
D
E
N
T
*PLEASE PRINT*
Place of Employment:
Cell Phone:
Resides with:
Yes
No
Brothers & Sisters (Oldest First)
Name:
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found.
DOB:
Name:
DOB:
Name:
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found.
DOB:
Name:
DOB:
Name:
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found.
DOB:
Name:
DOB:
OTHER CONTACT INFORMATION
Please list three people we may call if the parent(s) or guardian(s) cannot be reached in the event of an emergency. These people also have your permission
to pick your child up from school during the day.
Name of Person
Relationship
Language
Phone Number
Signature of Parent/Guardian:
Date:
***Continue***
BINGHAMTON CITY SCHOOL DISTRICT
EMERGENCY CARE/CONTACT INFORMATION
In case of an emergency, the school staff will contact 911. Every attempt will be made to contact
a parent, a guardian or a designated contact.
*PLEASE PRINT*
S
T
U
D
E
N
T
I
N
F
O
*PLEASE PRINT*
Full name:
(First
Middle
Date of Birth:
Last)
Gender
Male
Building:
Female
Grade:
Teacher/Counselor:
Below list any current health condition that may require attention during the school day.
A
L
E
R
G
I
E
S
List all allergies your child has:
Foods:
Reaction:
Medicines:
Reaction:
Insects:
Reaction:
Other:
Reaction:
ASTHMA
Triggers:
Hearing Condition:
Heart Condition:
Eye or Vision Condition:
Corrective Lenses:
Respiratory Disorders:
Nervous System Disorders:
Yes
No
Blood Disorders:
Migraines:
Date of
Onset:
Seizures & Type:
Skin Condition:
Diabetes:
Learning Disability:
Physical Disability:
History of Communicable Disease:
Other:
PHYSICIAN INFORMATION
Primary Care Provider:
Telephone:
Specialist Care Provider:
Telephone:
Dentist:
Telephone:
Medical
Insurance:
Preferred Emergency Room or Hospital:
If NO, may we have Child Health Care Plus contact you?
Yes
No
Yes
No
Provider:
Signature:
MEDICATIONS
List all Medications and dosages your child receives on a regular basis:
Will student need to take medication at school?
Yes
No
A written Doctor’s order is necessary for medications that will be given at school.
The school has my permission, in an emergency when I cannot be contacted, to take my child to the nearest appropriate medical facility, and the facility and its
medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child. I verify that the above information is true
and correct and I understand that this information may be shared with personnel involved with my child.
Signature of Parent/Guardian:
Date: