11 Foxcroft Drive Livingston, NJ 07039 Phone: 973-535-8000 FAX: 973-535-1254 www.livingston.org PRIDE/Integrated Pre-School Program New Student Registration Process Only a parent or legal guardian may register a student in the Livingston School District. Registration Packets are available from the Administrative Offices or may be downloaded from our website. Completed registration packets can be returned to the Board of Education office by contacting Amy Ennis, Registrar, to set up an appointment. Amy Ennis may be reached at (973) 535-8000 Ext. 8002. To process a new student registration, please complete and supply the following documentation for your student: Original Birth Certificate Student Registration Form LPS-REGISTRATION-01PK Parent/Guardian Information Form LPS-REGISTRATION-02PK NJ SMART Information Form LPS-REGISTRATION-03PK Please note that additional documentation is required for the following circumstances: If Parents/Guardians live at more than one residence, regardless of which parent has legal custody, court documentation of the custody agreement must be supplied. If Legal Guardian, court documentation of guardianship is required. If Guardian for a student with parents who do not reside in Livingston, complete forms LPSREGISTRATION-AFFIANT, Affidavit of Domiciliary and Affidavit of Non-Resident Parent/Guardian. The following Health Services information must be completed and returned with the registration packet. No student will be admitted to any school in our district without evidence of having been immunized. Student Medical Examination/Immunization Record Form LPS-REGISTRATION-HEALTH-01PK Dental Form LPS-REGISTRATION-HEALTH-02PK Confidential Medical Information Form Mantoux Tuberculin Notification Form LPS-REGISTRATION-HEALTH-03PK (if applicable) If your student plans on participating in interscholastic or intramural sports, please visit the athletic department pages for additional information and required forms. Revised 4/2014 LPS-PRESCHOOL-REGISTRATION Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org Depending upon your circumstances, the parent/guardian should supply the documents listed below*: Proof of Ownership for Student Living with Parent/Guardian who is a Livingston Homeowner: Original deed or tax bill PLUS Original of current month or one month prior’s utility bill Proof of Tenancy for Student Living with Parent/Guardian who is a Livingston Renter: Copy of lease PLUS Owner/Landlord Affidavit Form LPS-REGISTRATION-04PK PLUS Original of current month or one month prior’s utility bill Proof that Student and Parent/Guardian are Living with Other Family/Friend who is a Livingston Homeowner: Documentation from Homeowner: Letter from homeowner explaining living arrangements PLUS Original homeowner’s deed or tax bill PLUS Original current month or one month prior’s utility bill Documentation from Parent/Guardian of student: Bank statement PLUS Bill or pay stub Proof that Student and Parent/Guardian Living with Other Family/Friend who is a Livingston Renter: Documentation from Homeowner: Letter from homeowner explaining living arrangements PLUS Completed Owner/Landlord Affidavit Form LPS-REGISTRATION-04PK PLUS Renter’s copy of lease PLUS Original current month or one month prior’s utility bill Documentation from Parent/Guardian of student: Bank statement PLUS Bill or pay stub *PLEASE NOTE: If parent/guardian is unable to provide any of the documents listed above, please contact Amy Ennis, Registrar at 973-535-8000, x8002. NOTICE OF ELIGIBILITY: For the current school year, a child is eligible for entrance into kindergarten at the start of the regular school year if he/she has reached five (5) years of age on or before October 1 st, and a child is eligible for entrance into first grade at the start of the regular school year if he/she has reached six (6) years of age on or before October 1st. For additional information regarding Entrance Age, please refer to our Policy #5112 available under Policies on the district website. Revised 4/2014 LPS-PRESCHOOL-REGISTRATION Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program Last Name First Name Middle Name Nickname Grade Date of Birth Female Home Address Apt. # City State Home Phone Male Zip Cell Phone Previous Address: Home Address Apt. # City State Zip Language(s), other than English, spoken at home: Will your child require support in learning the English Language? Yes Check if your child currently has/previously had an IEP or 504 plan: No IEP 504 Plan Please provide explanation/documentation: The information above is true and correct. Fraudulent statements will be prosecuted to the full extent of the law. Signature of Registering Parent/Guardian Date The following documentation is required before your child may be admitted to our school. No child shall be admitted without proof of current complete required immunizations. Initial determination of eligibility is subject to thorough review and evaluation. Admission later found ineligible may be subject to assessment of tuition or removal from school. O FF I CE US E O NL Y Eligible for bussing? Health Records Yes No Immunizations Proof of Ownership/Tenancy (3) Home School Health Profile Deed Lease Dental Utility Bills Property Tax Bills Other Lease Expiration Date Birth Certificate Lease Affidavit Country City/State Guardianship/Custody Papers/Court Orders/Affidavit Additional Documents Needed Transcripts Student ID: Revised 4/2014 Date of Registration: LPS-REGISTRATION-01PK Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program (Parent/Guardian Information) Student Last Name First Name Parent/Guardian 1 (will be used as primary contact) First Name Last Name Relationship to Student Address City Own State Rent (complete Form LPS-REGISTRATION-04) Zip Other: Home Phone Primary Email Work Phone Other Email Cell Phone Cell Phone Provider (optional) Parent/Guardian 2 First Name Last Name Relationship to Student Address City Own State Rent (complete form LPS-REGISTRATION-04) Other: Home Phone Primary Email Work Phone Other Email Cell Phone Cell Phone Provider (optional) *Student Lives With: Parent/Guardian 1 and 2 Zip Parent/Guardian 1 Parent/Guardian 2 Other (please explain): *If a custodial agreement exists, custody papers or notarized statement from the custodial parent must be provided to allow for a second reporting account for the student (i.e., report cards, messages from administrators, etc.). Siblings/Other Children Living in the Household Full Name Date of Birth Gender School Female Male Female Male Female Male Female Male Grade The information above is true and correct. Fraudulent statements will be prosecuted to the full extent of the law. Signature of Registering Parent/Guardian Revised 4/2014 Date LPS-REGISTRATION-02PK Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program NJ SMART Information New Jersey Standards Measurement and Resource for Teaching (as required by the State of New Jersey) Last Name First Name Middle Name Date of Birth Female Male Date of Entry Into First US School (if applicable): (To be completed by the district.) (To be completed by district if not a transfer student.) Student ID State ID Ethnic Group (check all that apply) White Black Hispanic American Indian/Alaskan Asian Hawaiian Native/Other Pacific Islander Language Primary Language Spoken Other Language(s) Spoken Health Information Physician’s Name Address City Phone State Zip FAX Date of Last Exam: Does student have health insurance? Date of Last Lead Test: Yes (please specify provider): No If no, NJ FamilyCare provides free or low cost health insurance for uninsured children and certain low income parents. For more information call 800-701-0710 or visit www.njfamilycare.org to apply online. I hereby give Livingston Public Schools permission to release my name and address to the NJ FamilyCare Program to contact me about health insurance. Written consent required pursuant to 20 U.S.C. § 1232g(b)(1) and 34 C.F.R. 98.30(b). Signature: Printed Name: Date: For additional information regarding NJ SMART, visit http://www.state.nj.us/education/njsmart. Revised 4/2014 LPS-REGISTRATION-03PK Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program Owner/Landlord Affidavit (for those who rent their home) Owner/Landlord Information Last Name First Name Address Apt. # City Home Phone State Zip Alternate Phone Tenant Information Last Name First Name Address Apt. # City Home Phone State Zip Alternate Phone Leasing Information When did tenant(s) move in? Relation to Renter: How long is the lease agreement? None Family Member Friend Type of rental agreement: Yearly Month-to-Month Rent-to-Own List Names of all Persons Living in the Above-Named Residence 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. If applicable, please read and check: I am aware that said leasee has additional family members residing in subject property. I attest that to the best of my knowledge the information is true and correct, and I am aware that fraudulent statements or claims may be prosecuted to the full extent of the law. Sworn and subscribed before me this day of . Signature of Owner/Landlord (A Notary Public of New Jersey) Revised 4/2014 Date LPS-REGISTRATION-04PK 11 Foxcroft Drive Livingston, NJ 07039 Phone: 973-535-8000 FAX: 973-535-1254 www.livingston.org PRIDE/Integrated Pre-School Program Health Services Information All new students entering the Township of Livingston Public Schools must have the following healthrelated documentation on record prior to his/her first day of school: Pursuant to Title 8-Chapter 57, New Jersey Department of Health and Regulations require that all New Jersey pupils be immunized against Diphtheria, Tetanus, Whooping Cough (Pertussis), Polio, Measles (Rubeola), German Measles (Rubella) and Mumps. No pupil will be admitted to any school in our district without evidence of having been immunized by the following agents and a Certificate of Immunization History (included on Form LPS-REGISTRATION-HEALTH-01PK) completed and signed by a licensed health care provider: Diphtheria Toxoid Pertussis Vaccine Tetanus Toxoid Live Poliomyelitis Vaccine – Trivalent Live attenuated Measles Virus Vaccine and Measles Booster Vaccine Live Rubella Virus Vaccine Live Mumps Vaccine HIB Vaccine (required for all incoming kindergarten and pre-school students) Hepatitis B Vaccine Varicella Vaccine Pursuant to N.J.A.C. 6A:16-2.2, upon entering the school district each child must have an up-to-date physical examination (Form LPS-REGISTRATION-HEALTH-01PK). This examination must have been completed by a licensed health care provider no more than 365 days prior to entering school. Please return this form to the school nurse. Failure to submit Form LPS-REGISTRATION-HEALTH-01PK could result in your child’s exclusion from school. Student Medical Examination/Immunization Record Form LPS-REGISTRATION-HEALTH-01PK Dental Form LPS-REGISTRATION-HEALTH-02PK Confidential Medical Information Form Mantoux Tuberculin Notification Form LPS-REGISTRATION-HEALTH-03PK (if applicable) Revised 4/2014 LPS-REGISTRATION-HEALTH-PK Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program Student Medical Examination (to be completed by a licensed health provider) Student Name: Date of Birth: Female Male Home Address: School: Grade: Growth and Development: Normal Premature Term Complications Early illness or injury Systems Review: Height Weight Vision: R L Audio: R L BMI B Blood Pressure Glasses/Contacts EENT Speech Integument Head & Neck Lymphatic Respiratory Cardiovascular Abdomen Gastrointestinal Genitourinary Urinalysis Musculoskeletal Hernia Scoliosis Nervous Emotional Symptoms Nutrition Neurological/Psychological: General Assessment: Remarks (Please list any special needs and/or medication required.): Medical History: Year Year Year Allergies Asthma Ottis Media Drug Sensitivities Chicken Pox Rheumatic Fever Lyme Disease Seizure Disorder Strep Infections Hepatitis Diabetes Mononucleosis Neuromuscular Disease Heart Disease Other Year Operations/Injuries Hospitalizations Congenital Defects (PLEASE USE PAGE 2 FOR IMMUNIZATION HISTORY.) Revised 6/2015 LPS-REGISTRATION-HEALTH-01PK Student Name: Immunization History: DTaP: 2. 1. mm/dd/yy 3. mm/dd/yy 4. mm/dd/yy Tdap: Polio 1. OPV: 1. MMR: Measles: 2. mm/dd/yy 1. 4. 5. mm/dd/yy mm/dd/yy mm/dd/yy 2. mm/dd/yy 2. mm/dd/yy HIB Vaccine: mm/dd/yy 3. mm/dd/yy mm/dd/yy Rubella: 5. mm/dd/yy mm/dd/yy 2. 1. 1. 3. mm/dd/yy mm/dd/yy Booster 4. mm/dd/yy 2. 1. Mumps: 3. mm/dd/yy mm/dd/yy mm/dd/yy Booster (for students born after January 1997 and students entering Grade 6) IPV: 5. mm/dd/yy mm/dd/yy 2. mm/dd/yy mm/dd/yy 2. 1. mm/dd/yy Hepatitis A Vaccine: Hepatitis B Vaccine: PPD Mantoux: Lead Test: 3. mm/dd/yy mm/dd/yy 2. 1. mm/dd/yy (mandatory for incoming Grade 6 students) mm/dd/yy Results: 2. 1. mm/dd/yy 2. 1. mm/dd/yy (mandatory for pre-school students) Meningococcal Vaccine: 3. Lead Level: mm/dd/yy (mandatory for pre-school students) mm/dd/yy Date Read: Date Tested: Pneumonoccal Vaccine: mm/dd/yy mm/dd/yy Date Tested: Influenza Vaccine: 5. mm/dd/yy 2. 1. Varicella Zoster: 4. mm/dd/yy 3. mm/dd/yy 4. mm/dd/yy mm/dd/yy 1. mm/dd/yy 2. 1. mm/dd/yy 3. mm/dd/yy mm/dd/yy Other (specify): Date of Examination: Revised 6/2015 Physician’s Signature: LPS-REGISTRATION-HEALTH-01PK Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program Dental Form Student Name: Date of Birth: Name of School: Grade: Date of Dental Exam: Describe dental care student requires: Name of Dentist: Address of Dentist: Dentist’s Phone Number: Signature of Dentist Revised 4/2014 Dentist’s FAX Number: Date LPS-REGISTRATION-HEALTH-02PK Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org Confidential Medical Information Form* (Form to be completed by parent/guardian.) _______________ School Year Student ID: Student’s Name: Grade: Physician’s Name: Teacher: Office Phone Number: Does your child take any medication regularly? If yes, complete below. Medication: Dosage: Time Administered: Dosage: Time Administered: Dosage: Time Administered: Purpose of Medication: Medication: Purpose of Medication: Medication: Purpose of Medication: The school nurse has my permission to administer the following medications to my child during the school day: Tylenol/Acetaminophen Tums Advil/Motrin/Ibuprophen Cough Drops Does/Did your child have any of the following? If YES, please give details below. Allergies (pollen, food, hives, medicine): List allergens and types of reactions below: (If an EpiPen injection is necessary, a “permission to dispense” form must be submitted every school year.) Yes No Asthma (allergic, exercise induced) – describe symptoms and treatment below: (If an inhaler is necessary, a “permission to dispense” form must be submitted every school year.) Bee Stings (If YES, you MUST provide medication.) Hearing Difficulties Eyeglasses/Contact Lenses – when should they be worn? Fainting with Exercise Any previous joint disease, injuries, fractures? Loss of consciousness after injury? Diabetes Heart problems, chest pain, palpitations, murmur? Surgery(ies) – list dates and reason below: (Page 1 or 2) Revised 6/2015 CONFIDENTIAL MEDICAL INFORMATION FORM Has your child ever been hospitalized? If YES, please give details below. Hospitalization(s) – list date and reason below: Yes No Do you have any concerns about your child’s health that would impact on his/her role as a student? If your child has a history of allergies, takes medication, wears eyeglasses/contacts or has any health related concerns, it is important to give that information to the school nurse. The Family Education Rights and Privacy Act (FERPA) has issued regulations which require public schools to obtain written consent to disclose medical information. All information will be held in the confidence by the school nurses and will be shared only with other school professionals as necessary. If you have any concerns or question please do not hesitate to contact the school health office. I give my permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school. Signature of Parent/Guardian Date NOTE: Height and weight yearly screening information will be transmitted by the school nurse for students in grades 4 through 12 to their Physical Education teacher. This data may be used in conjunction with the PE Fitness Assessment Program (Fitnessgram) to provide students and parents with information about their overall health and fitness level as part of the educational program. Check here ____ if you do not agree with sharing your child's height and weight for their physical education program. Does your child have health insurance including NJ FamilyCare/Medicaid, Medicare, private or other? YES, my child has health insurance. NO, my child does not have health insurance; you may release my name and address to the NJ FamilyCare Program to contact me about health insurance. I give my permission for release on this form for confidential use in meeting my child’s health and educational needs in school. Print Name of Parent/Guardian Signature of Parent/Guardian Date *Athletes (including intramurals) in grades 6-12 must also complete the Annual Athletic Pre-Participation Physical Examination Form which is required by the State of New Jersey prior to participation as per N.J.A.C. 6A:16 Programs to Support Student Development. This form can be found on our district, middle and high school websites. Revised 6/2014 CONFIDENTIAL MEDICAL INFORMATION FORM Livingston Public Schools 11 Foxcroft Drive Livingston, NJ 07039 973-535-8000 www.livingston.org PRIDE/Integrated Pre-School Program Mantoux Tuberculin Testing Notification Form Student’s Name: Date: In accordance with the rules of the State Department of Education, New Jersey Department of Health and Senior Services' most recent mandate of July 2005, as well as procedures followed by the Livingston School District: "All students entering New Jersey schools require tuberculin skin testing when entering the school system for the first time, if BORN in, or TRANSFERRING from, a high TB incidence country NOT listed below." A further exemption exists "if the student has a documented Mantoux Tuberculin skin test result within the previous six (6) months of school entry." As mandated by state law, the method of screening to be used is the Mantoux Intradermal Skin Test. Within 48 - 72 hours, the site of the test must be checked and the results documented. The Mantoux test may be done by the school nurse or a local private physician if you prefer. Students will not be allowed to attend school until this testing has been completed. Thank you for your cooperation in this matter. New entry or transfer students from the following countries are exempt from Mantoux Tuberculin skin testing: Antigua and Barbuda Belgium Cuba Finland Grenada Italy Luxembourg Netherlands Oman Sweden USA Revised 4/2014 Australia Bermuda Cyprus France Iceland Jamaica Malta Netherlands Antilles Puerto Rico Switzerland USA Virgin Islands Austria Canada Czech Republic Germany Ireland Jordan Monaco New Zealand Barbados Cayman Islands Denmark Greenland Israel Lebanon Montserrat Norway Saint Kitts and Nevis Trinidad and Tobago San Marino United Kingdom of Great Britain and Northern Ireland LPS-REGISTRATION-HEALTH-03PK