CHELMSFORD PUBLIC SCHOOLS
CHELMSFORD, MASSACHUSETTS
STUDENT REGISTRATION – GRADES K-4
& CHIPS PRESCHOOL
Student Data
1.
2.
Last Name:
Grade level student is entering:
First Name:
Does this student currently receive special services? Yes
Middle Name:
□
□
No
If yes, I.E.P. □
3.
Has this student ever received special services in the past? Yes □
If yes, please explain:
4.
Has this student been registered as a student in Chelmsford Public Schools?
No
504 □
□
Does the student have any siblings registered in Chelmsford Public Schools?
□
Yes □
Yes
No □
No
□
Sibling’s name/current grade level:_________________________________________________
_________________________________________________
5.
_________________________________________________
Each student enrolled in Chelmsford Public Schools has a unique user name, also known as a log in. Parents can retrieve this
information online by using the X2 Aspen Family Portal. This information is commonly found on report cards or student
schedules for middle and high school students.
6.
Date of Birth:
7. City/Town of birth:
8. Student’s home phone:
9. Student resides at this address:
10. Student’s primary language spoken at home:
11. Student’s race:
Gender: Female
Country of Origin:
White □
Asian □
American Indian or Alaska Native □
Native Hawaiian or Other Pacific Islander □
□
Male □
Black or African American □
12. Student’s Ethnicity:
Are you Hispanic or Latino? (select one) No, Not Hispanic or Latino □
Yes, Hispanic or Latino*
□
*A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race.
13.
Parent E-Mail Address: _______________________________________________________________
First Parent/Guardian Contact Information
1st Contact Name
Relationship
Lives w/student?
Yes □
Address (if different than
Email Address
No □
Workplace
student)
Custody issue Yes
□
Home Phone (Alt.)
Mobile Phone (Alt.)
Yes □
No □
Work Phone (Alt.)
Second Parent/Guardian Contact Information
Relationship
Lives w/student?
Yes □
Address (if different than
Email Address
No □
Workplace
student)
Custody issue Yes
Home Phone (Primary)
Mobile Phone (Primary)
Home Phone (Alt.)
Mobile Phone (Alt.)
Work Phone (Primary)
Work Phone (Alt.)
No □
□
No
□
□
No □
Yes □
No □
Unlisted?
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
First Emergency Contact if Parents/Guardians CAN NOT Be Reached
Relationship
Can Dismiss Student? Can Receive Student?
Lives w/student?
Yes □ No □
Yes □ No □
Yes □ No □
Contact Name
Address (if different than student)
Email Address
Phone Numbers
Work Phone (Primary)
Unlisted?
Yes □ No □
Yes □ No □
Yes □ No □
Work Phone (Alt.)
Yes □ No □
Home Phone (Primary)
Mobile Phone (Primary)
Home Phone (Alt.)
Mobile Phone (Alt.)
Contact Name
□
No
Can Dismiss Student? Can Receive Student?
If yes, is this contact a custodial parent? Yes
Yes □
Phone Numbers
□
Unlisted?
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Work Phone (Primary)
2nd Contact Name
□
No
Can Dismiss Student? Can Receive Student?
Phone Numbers
Home Phone (Primary)
□
If yes, is this contact a custodial parent? Yes
Yes □
Mobile Phone (Primary)
No
Second Emergency Contact if Parents/Guardians CAN NOT Be Reached
Relationship
Can Dismiss Student? Can Receive Student?
Lives w/student?
Yes □ No □
Yes □ No □
Yes □ No □
Address (if different than student)
Email Address
Phone Numbers
Home Phone (Primary)
Mobile Phone (Primary)
Unlisted?
Yes □ No □
Home Phone (Alt.)
Mobile Phone (Alt.)
Yes □ No □
Work Phone (Primary)
Yes □ No □
Work Phone (Alt.)
Yes □ No □
CHELMSFORD PUBLIC SCHOOLS
CHELMSFORD, MASSACHUSETTS
ENGLISH LANGUAGE EDUCATION
HOME LANGUAGE SURVEY
STUDENT’S FIRST NAME: _______________
A ge: _ _ _ _ _
STUDENT’S FAMILY NAME: __________________
B ir th da t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Gra de: _ _ _ _ _ _ _
Ge n der:
M
F
Re la t i o ns h ip of Pe rs o n Co m pl et i ng S ur ve y:
M o t her
F a th er
Gua rd ia n
O t her S pec i fy: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Dear P a re nt s a nd G u ar d i an s :
I n o rd er to he lp yo ur c h ild s u cce ed i n sc ho o l, we as k t ha t yo u p l ea se a n s we r t he fo l lo wi n g q u es tio n s
fo r eac h c hi ld i n yo ur f a mi l y. Yo ur a n s wer s wi l l he lp u s i n t he crea ti n g o f t he b e st p o s sib le
ed u cat io na l p ro gr a m fo r yo ur c hi ld .
1.
W ha t l a n g ua ge d id yo ur ch ild f ir st u nd er st a nd o r sp e a k? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2.
W ha t l a n g ua ge d o yo u u se mo s t o ft e n wh e n sp ea ki n g wi t h yo ur c hi ld a t ho me? _ _ _ _ _ _ _ _ _ _ _ _
3.
W ha t l a n g ua ge d o e s yo u r c hi ld u se mo st o fte n whe n sp ea ki n g wi t h yo u a t ho me? _ _ _ _ _ _ _ _ _ _
4.
W ha t l a n g ua ge d o e s yo u r c hi ld u se mo st o fte n whe n sp ea ki n g wi t h o t her fa mi l y me mb er s?
_____________________________
5.
W ha t l a n g ua ge d o e s yo u r c hi ld u se mo st often when speaking with friends? ____________________
6.
W ha t l a n g ua ge s( s) d o es yo ur c hi ld r ead ? _____________ ________________ _______________
7.
W ha t l a n g ua ge ( s) d o e s y o ur c hi ld wr it e? _____________ ________________ _______________
8.
At wh a t a ge d id yo ur c h ild st ar t at te nd i n g sc ho o l? _________________________
9.
Ha s yo ur c h ild at te nd ed sc ho o l e ve r y year s i nce th at a ge?
10.
Ye s
No
W o uld yo u p r e f er o r a l a nd wr i tt e n co m mu n i c at i o n fr o m t he s c ho o l i n E n gl i s h o r i n yo ur ho me
la n g ua ge? ____________________
11.
Ha s t h e st ud e n t e v er b e e n i n a b il i n g ua l ed uc at io na l o r a n E n gl i s h a s a S eco nd La n g u a ge p ro gr a m?
Yes
12.
No
Did t he st ud e nt e xi t t h e p r o gr a m?
Yes
No
Exit Date: ___________
F AM I L Y H IS T O R Y
I f a n y o f t he fo llo wi n g p eo p le wo r k o r li v e i n t he s t ud e n t ’s ho me, li s t t he la n g u a ge s t h e y sp ea k (i nc l ud i n g
En g li s h).
LANGUAGES
USED MOST
U S E D S E C O N D U S E D T H IR D
Fat h er, g u ard ia n , step f at her
_________
___________ __________
Mo t her , g uard ia n, s tep m o th er
_________
___________ __________
Ot her c hi ld re n o r sib l i n g s
_________
___________ __________
Gr a nd p ar e nt
_________
___________ __________
B ab ys itt er
_________
___________ __________
Ot her
_________
___________ __________
Nu mb er o f Y ea r s St u de nt i n US A: _ _ _ _ _ _ _ _ _ _ _
MIGRANT STATUS:
ELIGIBLE
NOT ELIGIBLE
A n i nd ica ti o n of wh e th er a n I nd iv id ua l o r P a r en t / Gua rdia n a cc o mpa n yi n g a n i nd iv id ua l ma i nt a i n s
pri ma r y e m pl o y me nt i n o ne or m ore a gr ic ul t ura l o r fi s hi n g a c ti vi t i es o n a s ea s o n a l or ot h er te m p ora r y
ba s is a n d e sta bl is h es a te mp ora ry re sid e nce f or t he p ur p ose s of s uc h e m pl o y me nt.
EMERGENCY IMMIGRATION EDUCATION PROGRAM STATUS:
ELIGIBLE
NOT ELIGIBLE
A n i ndi ca t i o n of wh et her a s tu de nt i s e li g ib l e f o r t he E mer ge nc y I m mi gra n t Ed uca ti o n P ro gra m. T o b e
eli g ib le f or t he pr og ra m, a s tud e nt m us t:
1.
No t ha v e be e n b or n i n a n y S ta te; A N D
2.
No t ha v e c o mp le ted t h ree ( 3 ) f u ll a ca de m ic y ea rs of sc h o ol i n a n y S ta te.
*A ls o, if a s tud en t is e li gi bl e, C o u nt ry of O ri gi n m us t be p ro vi ded.
Sig na t ure o f Pa r ent / G u a rd ia n: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
T o be fille d o ut b y a p pr op ri a t e s ch ool pe rs onne l:
Reco mme n da t io ns:
Pro f ic ie ncy T es ti ng / Re co rd s Rev iew
No E LE S erv i ce s
EMERGENCY CONTACT / MEDICAL INFORMATION
Chelmsford Community Education / Elementary Students
PRIMARY SCHOOL____________ PROGRAM (If CommEd
)____________GRADE____TEACHER_________
CHILD'S NAME __________________________________________________DOB____________ AGE____ BUS # _________
GENDER_________EYE COLOR___________ HAIR COLOR______________ HEIGHT_____________ WEIGHT_________
IDENTIFYING MARKS_____________________________________________________________________________________
Are there any custody concerns regarding this child?
*YES_______
NO________
*In order to comply appropriately, the proper legal documentation must be received by the school office and Chelmsford Community
Education if program used.
CHILD'S ADDRESS _____________________________________________________________________________________
WHO DOES THE CHILD LIVE WITH______________________________
MOTHER/GUARDIAN’S NAME _______________________________HOME PHONE (______)______________________
HOME ADDRESS _______________________________________ CELLULAR (______)_____________________
PLACE OF EMPLOYMENT________________________________ WORK PHONE (_____) __________________
FATHER/GUARDIAN’S NAME _______________________________HOME PHONE (______)_______________________
HOME ADDRESS _________________________________________CELLULAR (______)_____________________
PLACE OF EMPLOYMENT________________________________ WORK PHONE (_____) __________________
PRIORITIZE # FOR QUICK CONTACTING (Call 1st, 2nd etc…)
MOTHER’s _____(H) ______(W) _______(C)
FATHER’S _____(H) ______(W) _______(C)
*SIBLING INFORMATION – If applicable, please list all siblings, ages, and current schools
_________________________________________________________________________
If parent/guardian not available, list the persons you wish to be called and authorized to pick up your child:
Name___________________________Relationship__________________How refers to individual_____________________
Contact numbers_____________________________________________________________________________________________
Name___________________________Relationship_________________ How child refers to individual_____________________
Contact numbers_____________________________________________________________________________________________
Name___________________________Relationship_________________ How child refers to individual_____________________
Contact numbers_____________________________________________________________________________________________
Please complete the following if your child goes to a day care/babysitter’s part time or every day:
NAME ____________________________ADDRESS ___________________________ PHONE (______)___________________
DAYS WITH DAY CARE/SITTER _____________________________________________________________________________
Parent/Guardian’s Signature: ________________________________
Date: ___________________
HEALTH INFORMATION
CHILD'S NAME _______________________________ DOB________ WEIGHT_______GRADE _____________ ROOM ______
DESIRED HOSPITALS_______________________________________________________________________________________
DOCTOR _______________________________________LOCATION_________________________ PHONE (_______)_____________________
EYE DOCTOR ___________________________________LOCATION__________________________ PHONE (_______)_____________________
DENTIST _______________________________________ LOCATION__________________________ PHONE _______)_____________________
*HEALTH INSURANCE _____________________________________ DENTAL INSURANCE __________________________
*If none write “None”. The school nurse is available to assist families locating free and or reduced cost insurance .
If needed, I give permission to the nurse to administer and/or apply the following medications that have been approved by our school
physician: acetaminophen(Tylenol), Caladryl, Oragel, Vaseline, Ibuprofen (Motrin/Advil), saline eye solutions, Bacitracin, Silvadene Cream,
hydrocortisone cream, diphenhydramine(Benadryl), and First Aid Cream? Yes  No 
____________________________________
(Parent/Guardian’s Signature required)
__________________
(Date)
If needed, I give permission to the nurse to share the following information with the appropriate school personnel to meet my child’s health,
safety, and/or educational needs?
Yes  No 
________________________________________
(Parent/Guardian’s Signature required )
I give permission to the nurse to speak with the above listed doctor to meet my child’s health and safety needs . Yes
________________________________________
(Parent/Guardian’s Signature required)
Allergies:
□My child has no allergies □My child has the following allergies
__________________
(Date)
No
__________________
(Date)
Is an Epi-pen Prescribed? *Yes__ No___
Medication child is allergic to:_________________________________ Environmental_______________________
*Foods_____________________________________________ *Bee/Insect__________ *Latex______**Other________________
*Each school year, an Allergy Medication Plan and Consent Form is required. If no medications are needed at school, then
documentation from the doctor indicating such is required.
Check all conditions that apply:
 ADD/ADHD
 Anxiety
 Asthma
 Arthritis
 Autism spectrum
 Bladder Control
 Constipation
 Celiac
 Diabetes
 Developmental Delays
 Ear Infections
 Eyeglasses/Contacts
 Gastric reflux
 Hearing Loss
 Heart Condition
 Heart Murmur
 Kidney
 Lactose Intolerant
 Migraines
 Nosebleeds
 Reflux (other)
 Seizures
 Scoliosis
 Strep throat infections (history of)
 Other
Hospitalizations this year? Yes  No 
reason? ____________________________________
Previous Concussions? Yes  No  Dates______
 Emotional Concerns?__________________________
Is an inhaler and/or nebulizer prescribed for your child? Yes  No 
Will it be sent to school? Yes  No 
Will it be sent to Community Education ?Yes  No 
Medications: Does your child take any daily or as needed medications at home? Yes  No  *if yes, please list
Medication_____________________Time of day ____________ Dose______________Required during school hours? Yes  No 
Medication_____________________Time of day ____________ Dose______________Required during school hours? Yes  No 
Medication ____________________Time of day _____________Dose______________ Required during school hours? Yes  No 
Medications necessary to be given during the school day and/or the CommEd Childcare programs, must submit to both offices: 1- written
physician’s order, 2-written parental permission, and 3 - be supplied and delivered by parent in the original labeled container.
Please list any other medical, emotional, health concerns/issues and/or past medical problem that limits activity at school or
can help the School Nurse care for your child: _____________________________________________
Parent/Guardian’s Signature: _____________________________________
Rev 09-2014
Date:__________________
Chelmsford Public Schools
Administration Offices
230 North Road, Chelmsford, MA 01824
Telephone: (978) 251-5100
Dr. Jay Lang, Ed.D.
Superintendent
C.O.R.I. (Criminal Offender Registration Information)
Dear Chelmsford Public School Parents and Volunteers:
In an effort to provide the safest school environment possible for students and staff, a federal law requires school
districts to conduct criminal background checks known as C.O.R.I.- Criminal Offender Registration Information,
on all employees and volunteers working with our children. This check also needs to be reviewed every three
years. All volunteers in the Chelmsford Public Schools are required to have submitted a C.O.R.I. form before
they are able to work with our students (application is attached). Please complete the necessary information, sign
the form and return it to the main office of your child’s school with a copy of your Massachusetts driver's license.
Even though you may have other children in a different school building or you are involved with scouts, youth
sports teams, etc., we are asking that you complete a form for each school in which you volunteer. Only one form
for all your children is required.
The Chelmsford Public Schools has a very large and successful volunteer program that includes library, computer,
classroom, fieldtrips, and P.T.O. volunteers. We truly appreciate the efforts of all our volunteers, so in order to
participate in these activities, individuals must complete this form. It is important to remember that you will not be
allowed to participate in volunteer activities without this background check.
Central Administration will be processing the C.O.R.I. checks through the Personnel Office. The information
obtained is reviewed only by authorized contact people, the Chelmsford Superintendent of Schools and the
Director of Personnel. All information will be held in the strictest confidence. Thank you for your understanding
in this matter.
As of October 2007 the federal law changed. This new form requires personal information such as sex, height,
weight and eye color and a copy of your driver's license. You will need to bring the completed form to the main
office of your child’s school. At that time your license will be verified and the application signed off on the CORI
form, which will then be forwarded to Central Administration. No copies will be kept at the schools. Each school
will have a list of all CORI forms submitted and when they expire. You can always call the individual schools to
check on your C.O.R.I. status to make sure it is still in effect.
Sincerely,
Dr. Jay Lang, Ed.D.
Superintendent
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
Criminal Offender Record Information (CORI)
Acknowledgement Form
_________________Chelmsford Public Schools___________________________ is registered under the
(Organization)
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 _________Chelmsford Public Schools____________________
(Organization)
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 _____Chelmsford Public Schools______
(Organization)
with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
The ___________________Chelmsford Public Schools____________________________________ may conduct
(Organization)
subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that
______________________ Chelmsford Public Schools______________________________, must first provide me
(Organization)
with written notice of this check.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this
Acknowledgement Form is true and accurate.
_________________________________________________________ ____________________________
Signature of CORI Subject
Date
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
SUBJECT INFORMATION
Please complete this section using the information of the person whose CORI you are requesting.
The fields marked with an asterisk (*) are required fields.
* First Name: ________________________________________________________ Middle Initial: _________________
* Last Name:_________________________________________________________ Suffix (Jr., Sr., etc.): _____________
Former Last Name 1: _______________________________________________________________________________
Former Last Name 2: _______________________________________________________________________________
Former Last Name 3: _______________________________________________________________________________
Former Last Name 4: _______________________________________________________________________________
* Date of Birth (MM/DD/YYYY): ___________________ Place of Birth: ________________________________________
* Last SIX digits of Social Security Number: ___ ___ ‐‐ ___ ___ ___ ___ ☐ No Social Security Number
Sex: _________________ Height: _____ ft. _____ in. Eye Color: _______________ Race: ______________________
Driver’s License or ID Number: ______________________________________ State of Issue: ____________________
Father’s Full Name: ________________________________________________________________________________
Mother’s Full Name: _______________________________________________________________________________
Current Address
* Street Address: ____________________________________________________________________________________
Apt. # or Suite: _____________ *City: __________________________ *State: ________ *Zip: _______________
SUBJECT VERIFICATION
The above information was verified by reviewing the following form(s) of government‐issued identification:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Verified by:
_______________________________________________________
Print Name of Verifying Employee
___________________________________________________________ __________________________
Signature of Verifying Employee
Date
CHELMSFORD PUBLIC SCHOOLS
CHELMSFORD, MASSACHUSETTS
RELEASE OF RECORDS REQUEST
DATE: _______________________ D.O.B.: _________________________ GRADE: ___________________
I give my permission for the ______________________________________________________________School
(School Last Attended)
__________________________________________________________________________________________
(Address)
(Telephone)
To forward my child’s,_________________________________________student transcript/records to:
(Student’s Name)
Byam Elementary School
25 Maple Road
Chelmsford, MA 01824
978-251-5144 FAX: 978-251-5150
McCarthy Middle School
250 North Road
Chelmsford, MA 01824
978-251-5122 FAX: 978-251-5130
Center Elementary School
84 Billerica Road
Chelmsford, MA 01824
978-251-5155 FAX: 978-251-5160
Parker Middle School
75 Graniteville Road
Chelmsford, MA 01824
978-251-5133 FAX: 978-251-5140
Harrington Elementary School
120 Richardson Road,
North Chelmsford, MA 01863
978-251-5166 FAX: 978-251-5170
Chelmsford High School
200 Richardson Road
North Chelmsford, MA 01863
978-251-5111 FAX: 978-251-5117
South Row Elementary School
250 Boston Road,
Chelmsford, MA 01824
978-251-5177 FAX: 978-251-5180
CHIPS PROGRAM
170 Dalton Road
Chelmsford, MA 01824
978-251-5188
_______CUMULATIVE RECORDS (which may include standardized test results, class rank, extracurricular
activities, I.Q. scores, evaluation forms, teacher, counselors, school staff, 766 evaluative materials, etc.)
________ALL HEALTH RECORDS
________SPECIAL EDUCATION RECORDS OR EDUCATIONAL PLANS (IEP/504) FOR THE STUDENT ABOVE
________STATE ID NUMBER
_____________________________________________
SIGNATURE OF PARENT/GUARDIAN
______________________
DATE