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.