52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
New Student Registration Process
Only a parent or legal guardian may register a student in the Riverdale 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 Candace Truax, Registrar, to set up an appointment. Candace Truax may be reached
at (973) 839-1300 Ext. 100.
Initial determination of eligibility for admission to the Riverdale Public Schools is subject to a
thorough review and there is a potential for assessment of tuition in the event that an initially
admitted student is later found ineligible pursuant to N.J.A.C. 6A:28-2.6. Any and all persons
who give fraudulent information for the purpose of attending the Riverdale Public Schools will be
prosecuted to the fullest extent of the law and sued for tuition for the student’s period of
ineligible attendance in the schools of the district.
To process a new student registration, please complete and supply the following documentation
for your student:










Original Birth Certificate
Student Registration Form
Home Language Survey
Publicity Consent Form
Parent/Student Assurance Form
Acceptable Use Form
Kindergarten Entrance Checklist Form from Parent
Kindergarten Entrance Checklist Form from Preschool/Nursey School/Daycare
Transfer Card (if transferring from another district)
Records Request Form (if transferring from another district)
The Health Services Information must be completed and returned with the registration
packet. No student will be admitted to our district without evidence of having been immunized:




Student Medical Examination
Student Health Information Release Form
Dental Form
Mantoux Tuberculin Testing Notification Form
If your child plans on participating in sports, please visit the nurse’s office for additional
information and required forms.
Revised 01/2016
RPS-REGISTRATION 1
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
In addition, the District requires at least three (3) documents demonstrating proof of residency.
The following list of documents are examples of documentation accepted by the District. The
District will not require disclosure of any of these documents as a condition of enrollment, and all
eligible students will be admitted into the District provided that the documentation submitted is
sufficient to demonstrate residency:
Proof of Residency (examples)
Must have one of the following:
 Original deed or property tax bill, or
 Copy of lease or signed notarized letter from landlord
In addition to the above, must have two additional proofs of residency:
 Original of current month or prior one month’s utility bill
 Bank or mortgage statement
 Bill or pay stub
 Vehicle registration
 Photo identification, such as driver’s license or passport (for the purpose of proof of
address only)
Moreover, if you are seeking to enroll a student pursuant to N.J.S.A. 18A:38-1(b) and N.J.A.C.
6A:22- 3.1(a)2, please complete and submit forms RPS-REGISTRATION-AFFIANT, Affidavit of
Domiciliary and Affidavit of Non-Resident Parent/Guardian.
NOTE: ENTRANCE AGES
Preschool Disabled - A child is eligible for entrance into a program of special education who
has attained his/her third birthday and has been found by the Child Study Team to be eligible for
a program for the preschool disabled in accordance with rules of the State Board of Education.
Preschool - A child is eligible to enter the lottery for entrance into our tuition preschool
program that will have attained the age of three years on or before October 1st of the year in
which entrance is sought.
Kindergarten - A child is eligible for entrance into kindergarten who will have attained the age
of five years on or before October 1st of the year in which entrance is sought.
First Grade - A child is eligible for entrance into first grade who will have attained the age of six
years on or before October 1st of the year in which entrance is sought.
Revised 01/2016
RPS-REGISTRATION 2
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Student Registration Form
Student Information
First
Name
Last
Name
Home
Address
Middle
Name
Apt. #
State
Date of
Birth
City
Zip
Home Phone
Female
City of Birth
Date of Entry Into First US School
(if applicable):
Male
State/Country of Birth
Ethnic Group
(check all that apply)
White
Asian
Black
Hispanic
American Indian/Alaskan
Hawaiian Native/Other Pacific Islander
Parent/Guardian* Information
(*Court documentation required for Guardianship)
Parent/Guardian 1 (will be used as primary contact)
First
Last
Relationship to
Name
Name
Student
Stat
Address
City
e
Own
Home
Phone
Rent
Other:
Home Email
Work Phone
Cell Phone
and
Provider
Parent/Guardian 2
First
Name
Active Duty (Full time) Army, Navy, Air Force,
Marine Corps, or Coast Guard
National Guard or Reserve
Not Military Connected
Last
Name
Address
Own
Zip
Relationship to
Student
Stat
e
City
Rent
Home Phone
Zip
Other:
Home
Email
Work Phone
Revised 01/2016
RPS-REGISTRATION 3
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Active Duty (Full time) Army, Navy, Air Force,
Marine Corps, or Coast Guard
National Guard or Reserve
Not Military Connected
Cell Phone
and Provider
Student
Lives With:
Parent/Guardian
Parent/Guardian 1 and 2
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.).
Emergency Contact (other than parent/guardian 1 or 2)
Emergency Contact Name
Relationship to Student
Address
Phone
Phone #2:
Emergency Contact Name
Relationship to Student
Address
Phone
Phone #2
Sibling Information
Name(s) of Sibling(s)
DOB (MM/DD/YY)
Do/Will they attend Riverdale?
Health Information
Physician’s Name
Address
City
Phone
Does student have
health insurance?
State
Zip
FAX
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 Riverdale Public Schools permission to release my name and address to the NJ FamilyCare
Program to contact me about health insurance.
Signature:
Printed Name:
Date:
Written consent required pursuant to 20 U.S.C. § 1232g(b)(1) and 34 C.F.R. 98.30(b).
Date of Last
Physical:
Date of Last Lead Test:
The information above is true and correct. Fraudulent statements will be prosecuted to the full
extent of the law.
Revised 01/2016
RPS-REGISTRATION 4
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Signature of Registering Parent/Guardian
Date
For additional information regarding NJ SMART, visit http://www.state.nj.us/education/njsmart.
Home Language Survey*
Parent/Guardian Language Questionnaire
Last Name
First Name
Age
Date of School Entrance
Person completing the survey: [ ] Mother [ ] Father [ ] Grandparent
[ ] Guardian
[ ] Other
Directions: Check or write in the correct response for each of the following questions about your
child.
1. What language did the child learn when he/she first began to talk?
English______
Other [specify]___________________________________
2. What language does the family speak at home most of the time?
English______
Other [specify]___________________________________
3. What language does the parent/guardian speak to the child most of the time?
English______
Other [specify]___________________________________
4. What language does the child speak to his/her parent [guardian] most of the time?
English______
Other [specify]___________________________________
5. What language does the child speak to his/her brothers and sisters most of the time?
English______
Other [specify]___________________________________
6. What language does the child speak to his/her friends most of the time?
English______
Other [specify]___________________________________
7. In which language do you wish to receive school communication?
English______
Revised 01/2016
Other [specify]___________________________________
RPS-REGISTRATION 5
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Signature:_____________________________________ Date:_______________
[person completing the survey]
*Adapted from the sample survey in A Manual for Community Representatives of the Title VI Steering Committee, published 9/76 by
the Institute for Cultural Pluralism, Lau General Assistance Center, San Diego University, San Diego, CA 92182
Publicity Consent Form
First
Name
Last
Name
Home
Address
Grade
Home Phone
FERPA/DIRECTORY INFORMATION YEAR: 20__/20__
In compliance with New Jersey State Legislature Bill A592, Riverdale Public School District is
requesting permission for your child’s photo/image and personally identifiable information to be
published for district use. The district would like to celebrate student work and achievements on
our website, district social media, local newspapers, and other district multimedia. As you are
aware, there are potential dangers associated with the posting of personally identifiable information
on the internet. The law requires that we ask for your permission to use information about your
child.
Pursuant to law, we will not release any personally identifiable information without prior written
consent from you as a parent or guardian. If you, as the parent or guardian, wish to rescind this
agreement, you may do so at any time in writing by sending a letter to the principal of your child’s
school and such rescission will take effect upon receipt by the school.
YES – I do grant Riverdale Public School District permission to use my child’s
photo/image for uses stated above including personal identifiers.
YES – I do grant Riverdale Public School District permission to use my child’s
photo/image for uses stated above with no personal identifiers.
NO – I do not want my student photographed for any reason except class
pictures
Revised 01/2016
RPS-REGISTRATION 6
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Signature of Parent/Guardian
Revised 01/2016
Date
RPS-REGISTRATION 7
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Last
Name
Home
Address
Parent/Student Assurance
First
Name
Grade
Home Phone
We have read the Riverdale Public and Parent Handbook and have discussed its contents,
rules, polices, and regulations along with my child. We will follow through on all matters
discussed in the handbook as well as those, which arise during the school year. Failure to
abide by the rules and those deficiencies identified may result in disciplinary action being
taken towards my child.
Signature of Parent/Guardian
Date
Signature of Student
(Grade 5-8 only)
(Grade Prek-4 is Parent signature only)
Date
Revised 01/2016
RPS-REGISTRATION 8
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Acceptable Use Form
Last Name
Home
Address
Parent
Last Name
First Name
Grade
Parent First
Name
Home Phone
Relationship
to Student
ACCEPTABLE COMPUTER, INTERNET AND ELECTRONIC MAIL USE
AGREEMENT
This form is to be completed after reviewing the Riverdale Board of Education Acceptable Use Policy No.
2361 and all documents incorporated into that Policy by reference. The completion of this form indicates
that the student and his/her parent(s)/guardian(s) agree to abide by the terms and conditions of the
Policy. This form must be signed by the student and his/her parent(s)/guardian(s) before the student
will be permitted to access to the District Network or Computer System.
STUDENT AGREEMENT
I have read the Riverdale Board of Education Acceptable Use Policy, (Policy No. 2361) and agree to
abide by the terms and conditions set forth therein. I understand that any access provided is designed
for educational purposes, and that if I fail to abide by the terms of Board Policy No. 2361, my access to
the District Network, Internet or Computer System may be suspended and that I may be subject to
additional discipline. I also understand that there may be criminal or civil consequences to my conduct
depending on the severity of my behavior. I accept all financial and legal liabilities, which may result
from my use of the Riverdale District Network, Internet or Computer System. I release the Riverdale
School District, its officers, employees, agents, representatives and all organizations and individuals
related to the Riverdale School District’s District Network, Internet or Computer System from any and
all actions, claims, costs, damages, liability or losses, including, but not limited to, attorney’s fees
incurred by the Riverdale School District relating to or arising out of my use of the District Network,
Internet or Computer System. I specifically agree to indemnify and hold the Riverdale Board of
Education, its Board members, employees, agents, servants and representatives harmless for any
actions, claims, costs, damages or losses, including, but not limited to attorneys’ fees, incurred by the
Riverdale Board of Education relating to, or arising out of my use of the District Network, Internet or
Computer System or any breach of this Agreement or the Acceptable Use Policy 2361.
I agree to keep my assigned password private, and not share it with any individual
other than my parent/guardian.
I also agree to report any misuse of the District Network, Internet or Computer System to my principal
or teacher. (Misuse can come in many forms, including messages sent or received that indicate or
suggest pornography, unethical or illegal solicitation, racism, sexism, terrorism or inappropriate
language, cyberbullying or inappropriate interactions with others on social networking sites and in chat
rooms.)
Revised 01/2016
RPS-REGISTRATION 9
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Signature of Student
Date
PARENT OR GUARDIAN AGREEMENT
I, (Print Name) __________________, as the parent/guardian of (print student’s
Name)__________________, hereby give my permission for my child to access the District
Network and to use the District computer system and Internet. I have read, understand and
agree to the terms and conditions of the Riverdale Board of Education Acceptable Use Policy
(Policy No. 2361), and agree to monitor my child’s use of the Internet and District Network
while he/she is at home to ensure that he/she is abiding by the procedures set forth therein. I
also recognize that some materials on the Internet may be controversial and objectionable and
that it is impossible for the Riverdale Board of Education to restrict access to all controversial
and objectionable materials. I will not hold the Riverdale Board of Education responsible for
any materials, or the accuracy or quality thereof, acquired or viewed on this network by my
child.
I understand that improper or inappropriate use of the District Network, Internet or Computer
System by my child may result in revocation or suspension of my child’s privilege to access
the network and/or computers, as well as the imposition of school discipline, criminal penalties
and/or civil penalties, and I accept all financial and legal liabilities resulting therefrom. I also
agree to pay for any charges or costs caused or incurred by my child through the use of a
school sponsored Internet account, and to report any misuse of the Internet through schoolsponsored accounts to my child’s teacher or principal.
I release the Riverdale Board of Education, its Board members, employees, agents, servants,
representatives and all organizations and individuals related to the Riverdale Board of
Education’s District Network, Internet or Computer System from any and all liabilities or
damages that may result from my child’s use of the Internet network. I specifically agree to
indemnify and hold the Riverdale Board of Education, its Board members, employees, agents,
servants and representatives harmless for any actions, claims, costs, damages or losses,
including, but not limited to attorneys’ fees, incurred by the Riverdale Board of Education
relating to, or arising out of my child’s use of the District Network, Internet or Computer
System or any breach of this Agreement or the Acceptable Use Policy by my child.
By signing this Agreement, I acknowledge that I have read and I understand this Agreement
and agree to accept its terms and conditions and the responsibility for guiding my child and
conveying to him/her appropriate standards for selecting, sharing and/or exploring
information.
Signature of Parent/Guardian
Revised 01/2016
Date
RPS-REGISTRATION 10
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
KINDERGARTEN ENTRANCE - CHECKLIST FOR PARENTS*
Last Name
First Name
DOB
Home Address
EMOTIONAL MATURITY:
Does your child:
1.
Have a positive self-concept?
2.
Show a sense of confidence when
doing most tasks?
Does your child separate easily from
you?
Initiate activities with other children?
(play, conversation)
Does your child respond to positive
redirection?
3.
4.
5.
6.
Most of
the Time
Sometimes
Never
Is your child easily frustrated?
Comments:
SOCIAL MATURITY:
Does your child:
7.
Interact well with other children?
(cooperates, takes turns)
8.
Prefer to play alone? Comments
9.
Has your child had preschool or play-group experience?
Yes
No
Most of
the Time
Sometimes
Most of
the Time
Sometimes
Never
Comments:
PHYSICAL MATURITY:
Does your child:
10. Can your child sit still and listen for a 5-10 minute period
of time? (excluding TV and video games)
Never
11. Can your child sit and concentrate on a task for at least 10
minutes? (excluding TV and video games)
12. Can your child button/zip his/her own clothing?
13. Is your child physically coordinated? (walks, runs without
tripping/falling)
Revised 01/2016
RPS-REGISTRATION 11
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
14. Are small muscle skills developed? (holds pencil with index
and middle finger low on the point, handles scissors well)
Comments:
INTELLECTUAL MATURITY:
Does your child:
Most of
the Time
Sometimes
Never
15. Enjoy being read to?
16. Listen to a story being read for 10+ minutes?
17. Can recall events in a story?
18. Have an interest in printed words?
19. Know their address and phone number?
20. Remember past events?
21. Recall words to songs and rhymes?
22. Have difficulty expressing wants and needs verbally?
23. Attempt to draw geometric forms? (square triangle, circle)
24. Identify primary colors?
25. Follow sequential directions?
26. Complete a suggested task?
27. Recognize some numbers and letters?
28. Express him/herself verbally?
29. Print his/her own first name?
Comments:
PLEASE CHECK ONE OF THE STATEMENTS BELOW:
After assessing my child's present behavior and past history, I feel he/she is ready for
Kindergarten for the 2016-2017 school year.
I am unsure about the appropriate placement for my child.
Signature of Registering Parent/Guardian
Revised 01/2016
Date
RPS-REGISTRATION 12
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
KINDERGARTEN ENTRANCE - CHECKLIST FOR NURSERY SCHOOL*
Last Name
First Name
DOB
Home Address
My child,
, is currently enrolled in the
________________________ school (include preschool, day care, nursery school, Head
Start, etc.). I give my permission for the school to provide the following information to
enhance the Kindergarten experience.
Signature of Registering Parent/Guardian
Date
Dear Preschool Teacher:
Please place a checkmark (X) in the appropriate column and comment if you feel it is
needed for clarification on the reverse side of this page. When the form is complete,
please mail to Riverdale Public School, 52 Newark Pompton Turnpike,
Riverdale, NJ 07457. Your assessment should reflect your most accurate evaluation.
At parents’ request, parent may review this information.
Yes
No
Sometimes
1. The child follows directions
2. The child completes classroom tasks
3. The child works independently
4. The child plays independently
5. The child works carefully
6. The child follows the school rules
7. The child has an adequate attention span
8. The child concentrates readily on the task at hand
9. The child demonstrates a positive attitude towards
school
10. The child interacts appropriately with other children
11. The child uses complete sentences during class
Revised 01/2016
RPS-REGISTRATION 13
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
discussion
12. The child exhibits self-confidence
13. The child works up to his/her ability
14. The child demonstrates self-control
15. The child appears comfortable and at ease doing
his/her work
16. The child possesses adequate large motor skills
17. The child possesses adequate small motor skills
PLEASE CHECK ONE OF THE STATEMENTS BELOW:
After assessing the child's present behavior and past history, I feel he/she should be
placed in Kindergarten for the 2016-2017 school year.
I am unsure about the appropriate placement for this child.
NOTES:
Comments:
Director/Teacher/Staff Member
Date
Please return directly to the school referenced on the front of this form as soon
as possible. We appreciate your assistance in endeavoring to help us place each
child appropriately.
Thank you for your cooperation.
Revised 01/2016
RPS-REGISTRATION 14
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
New Student Registration Process
Health Services Information
All new students entering the Riverdale Public Schools must have the following health-related
documentation reviewed and approved by a school nurse:





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 Student
Medical Examination) completed and signed by a licensed health care provider:
o Diphtheria Toxoid
o Pertussis Vaccine
o Tetanus Toxoid
o Live Poliomyelitis Vaccine – Trivalent
o Live attenuated Measles Virus Vaccine and Measles Booster Vaccine
o Live Rubella Virus Vaccine
o Live Mumps Vaccine
o HIB Vaccine (required for all incoming kindergarten and pre-school students)
o Hepatitis B Vaccine
o 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 (Student Medical Examination Form). 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
Student Medical Examination Form could result in your child’s exclusion from school.
Dental Examination Form
Student Health Information Release Form
Mantoux Tuberculin Notification Form
Revised 01/2016
RPS-REGISTRATION 15
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Dental Form
Student Name:
Date of Birth:
Parent/Guardian:
Grade:
Date of Dental Exam:
Describe dental care student requires:
Name of Dentist:
Address of Dentist:
Dentist’s Phone Number:
Signature of Dentist
Parent/Guardian Name (please print)
Revised 01/2016
Dentist’s
FAX
Number:
Date
Parent/Guardian Signature
Date
RPS-REGISTRATION 16
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Student Medical Examination
(to be completed by a licensed health provider)
Student Name:
Female
Male
Date of Birth:
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
Blood Pressure
B
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
Allergies
Asthma
Drug Sensitivities
Chicken Pox
Lyme Disease
Year
Year
Ottis Media
Rheumatic
Fever
Operations/Injuries
Seizure
Disorder
Strep Infections
Hospitalizations
Hepatitis
Diabetes
Mononucleosis
Neuromuscular Disease
Heart Disease
Other
Revised 01/2016
Congenital Defects
RPS-REGISTRATION 17
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Immunization History: (to be completed by a licensed health provider)
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
Varicella Zoster:
mm/dd/yy
2.
1.
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
4.
mm/dd/yy
5.
mm/dd/yy
mm/dd/yy
2.
1.
mm/dd/yy
2.
1.
mm/dd/yy
mm/dd/yy
3.
mm/dd/yy
Date Tested:
mm/dd/yy
Date Read:
Date Tested:
Results:
Lead Level:
Influenza Vaccine:
1.
Pneumonoccal Vaccine:
1.
2.
mm/dd/yy
(mandatory for pre-school students)
(mandatory for pre-school students)
Meningococcal Vaccine:
(mandatory for incoming Grade 6 students)
3.
mm/dd/yy
4.
mm/dd/yy
mm/dd/yy
mm/dd/yy
2.
1.
mm/dd/yy
3.
mm/dd/yy
mm/dd/yy
Other (specify):
Date of Examination:
Physician’s Name (please print)
Revised 01/2016
Physician’s Signature:
Office Address
Office Phone
RPS-REGISTRATION 18
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Student Health Information Release Form
(to be completed by a the parent/guardian)
Parents/Guardians: 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 confidence by the school nurse 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.
Date of
Birth:
Student Name:
Home Phone:
Grade:
Check one (if yes, please specify):
Allergies
Asthma
Hearing Difficulties
Vision Difficulties
Seizure Disorder
Orthopedic
Difficulties/Walking
Aides
Medications (list
condition and
dosage)
Yes
No
(If an EpiPen injection is necessary, a “permission to
dispense” form must be submitted every school year.)
Yes
No
(If an inhaler is necessary, a “permission to dispense” form
must be submitted every school year.)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Eyeglasses
Contact
Lenses
Other:
Other pertinent information (including hospitalizations within the last year):
I give permission for release of information on this form for confidential use in
meeting my child’s health and educational needs in school.
Parent Signature
Revised 01/2016
Parent Name
Date
RPS-REGISTRATION 19
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
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 Riverdale 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 Australia
Austria
Barbados
Belgium
Bermuda
Canada
Cayman Islands
Cuba
Cyprus
Czech Republic
Denmark
Finland
France
Germany
Greenland
Grenada
Iceland
Ireland
Israel
Italy
Jamaica
Jordan
Lebanon
Luxembourg
Malta
Monaco
Montserrat
Netherlands
Netherlands
New Zealand
Norway
Antilles
Oman
Puerto Rico
Saint Kitts and
San Marino
Nevis
Sweden
Switzerland
Trinidad and
United Kingdom of Great
Tobago
Britain and
USA
USA Virgin Islands
Northern Ireland
Revised 01/2016
RPS-REGISTRATION 20
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Records Request Form
Student Information
First
Name
Last
Name
Address
Home
Phone
City
Date of
Birth
M.I.
State
Zip
Female
Male
Previous School
Name of
School
Street
Address
Public
City
School Phone
Number
Last Day Student
Attended
State
School FAX
Number
Private
Zip
Official Records To Be Released
Grades/Transcript - District/State Assessments - Medical/Immunization Records
Special Education Records – Disciplinary Records
NJ State ID:
Is student in an ESL/Bilingual Program?
Yes
No
I hereby give permission for release of the above records and for the school district
to contact my child’s former district for further information. In addition to the
release of the above records to which you consent, the prior District will be releasing
the following mandated records for which your consent is not required: transcript of
grades, health records, attendance records, child study team records and disciplinary
records pursuant to N.J.A.C. 6:3-6.5.
Signature of Parent/Guardian
Office Use Only
Send Record Information
to:
Requested
By:
Date
Requested:
Date
Received
By:
Date
Received:
52 Newark-Pompton Turnpike
Riverdale, NJ 07457
Phone: 973-839-1300
FAX: 973-839-1024
http://www.rpsnj.org
Last Name
Owner/Landlord Affidavit
Owner/Landlord Information
First Name
Address
Apt. #
City
State
Home Phone
Zip
Alternate Phone
Tenant Information
Last Name
First Name
Address
Apt. #
City
State
Home Phone
Zip
Alternate Phone
Leasing Information
When did tenant(s) move in?
None
Relation to
How long is the lease
Family Member
Renter:
agreement?
Friend
Type of rental
Yearly
Month-toRent-to-Own
agreement:
Month
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 lease 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
day
this
of
.
Signature of Owner/Landlord
(A Notary Public of New Jersey)
Date