LAKELAND REGIONAL HIGH SCHOOL DISTRICT REGISTRATION INFORMATION FOR STATE RECORDS NINTH GRADE REGISTRATION DATE TODAY________ ENTRY DATE__________ STUDENT ID ______________LRHS ONLY STUDENT INFORMATION: DO NOT USE NICKNAMES: LIST CHILD’S FULL LEGAL NAME AS APPEARS ON BIRTH CERTIFICATE NAME_________________________________ (Last Name) ____________________________________ (First Name) __________________________ (Full Middle Name) DATE OF BIRTH____________ CITY AND STATE OF BIRTH ___________________ COUNTRY OF BIRTH____________ MALE____ FEMALE____ CURRENT AGE______ PLEASE READ AND SIGN THE STATEMENT BELOW BEFORE CONTINUING. I CERTIFY THAT I AM THE LEGAL GUARDIAN AND CUSTODIAL PARENT OF THE STUDENT LISTED ABOVE AND HAVE THE AUTHORITY TO REGISTER THIS STUDENT AT LAKELAND REGIONAL HIGH SCHOOL. X________________________________ (Parent/Guardian Signature) NAMES OF PARENTS/GUARDIANS/STEP PARENTS WITH WHOM CHILD RESIDES PLEASE LIST CORRECT TITLE ON RELATIONSHIP LINE ____________________________________ (Parent/Guardian Last Name) ___________________________________ (Parent/Guardian Last Name) _________________________________ (First Name) _________________________________ (First Name) ______________________ (Relationship) _______________________ (Relationship) HOME ADDRESS________________________________________________________________________________ (Number) (Street) (Town - Zip Code) HOME TELEPHONE NUMBER ____________________________________ DETERMINATION OF HOMELESS STATUS – See description on back page. Does this apply to you? ___yes ____no PLEASE LIST CELL PHONE AND E-MAIL INFORMATION FOR PARENTS/GUARDIAN WITH WHOM THE CHILD RESIDES. FATHER CELL PHONE ________________________________ FATHER E-MAIL:_____________________________ MOTHER CELL PHONE ________________________________MOTHER E-MAIL:____________________________ ETHNIC ORIGIN: (Check one) White____ Black or African American____ American Indian/Alaskan Native____ Hispanic or Latino_____ Asian_____ Native Hawaiian or Other Pacific Islander_____ FIRST LANGUAGE SPOKEN IN HOME____________________________ PLEASE COMPLETE OTHER SIDE OF REGISTRATION FORM EMPLOYMENT INFORMANTION FOR PARENT/GUARDIAN: PLEASE CIRCLE CORRECT TITLE BELOW: ______________________________________________________________________________________________________ Father/Guardian/Step-Father Name Occupation Employer Name (Area Code) Business Phone Number ______________________________________________________________________________________________________ Mother/Guardian/Step-Mother Occupation Employer Name (Area Code) Business Phone Number EMERGENCY INFORMATION - PERSONS TO CALL: The Lakeland Regional High School Crisis Management Plan has been developed in case a disaster occurs. Should there be such an emergency, or one of a personal nature (illness/accident), children may be released only to properly authorized parents/guardians or to the designees listed below. NAME___________________________________RELATIONSHIP_________________________________________________ EMERGENCY CONTACT HOME TELEPHONE _______________________ CELL NUMBER__________________________ NAME___________________________________RELATIONSHIP__________________________________________________ EMERGENCY CONTACT HOME TELEPHONE ______________________ CELL NUMBER___________________________ DOCTOR’S NAME ___________________________________________ DOCTOR’S # ________________________________ Does your child have Health Insurance? YES____ If Yes, Name of Insurance Company: ________________________________________________________________ NO_____ If No, NJ Family Care provides free or low cost health insurance for uninsured children. For more information see Current Medical Information Form in registration packet. List the Name, City and State of the Last School your child attended: ______________________________________________________ (School Name) _______________________ __________________________ (City) (State) _______________________________________ (Number and Street Address) ___________________ (Zip Code) I hereby certify that all the information provided on this form is true to the best of my knowledge. X________________________________________ (Parent/Guardian Signature) X________________________________________ (Student Signature) Determination of Homeless Status: A district board of education shall determine that a child is homeless when he or she resides in any of the following: A publicly or privately operated shelter designed to provide temporary living accommodations, including: Hotels or motels, congregate shelters, including domestic violence and runaway shelters, transitional housing and homes for adolescent mothers. A public or private place not designated for, or ordinarily used as a regular sleeping accommodation, including: Cars or other vehicles including mobile homes, tents or other temporary shelters, temporary shelters provided to migrant workers and their children on farm sites. The residence of relatives or friends with whom the homeless child is temporarily residing out of necessity because the family lacks a regular or permanent residence of its own or any temporary location wherein children and youth are awaiting foster care placement.