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