SIMSBURY PUBLIC SCHOOLS REGISTRATION FORM
Shaded Areas for Office Use
Registration Date:
School Entry Date:
School:
Student(s) Full Legal Name - list only the students currently registering and the grade level they will enter:
Last Name:
First Name:
Middle Name:
Preferred Name / Nickname:
Grade:
Gender:
D.O.B:
Birthplace (city/state):
For high school students – school year student first entered Grade 9:
Last Name:
First Name:
Preferred Name / Nickname:
Grade:
Assigned Student ID:
Middle Name:
Gender:
D.O.B:
Birthplace (city/state):
For high school students – school year student first entered Grade 9:
Last Name:
First Name:
Preferred Name / Nickname:
Grade:
Assigned Student ID:
Middle Name:
Gender:
D.O.B:
Birthplace (city/state):
For high school students – school year student first entered Grade 9:
Assigned Student ID:
(Enter up to 3 students above; use reverse side to register additional students)
Simsbury Home Address:
Mailing Address (if different):
Home Phone: (
Apt:
Zip:
Town:
Zip:
)
Ethnicity: Hispanic/Latino (circle one) Yes / No Race: Regardless of ethnicity, select one or more that apply (details on reverse side):
 American Indian/Alaskan Native
 Asian  Black/African American  Native Hawaiian/Other Pacific Islander  White
Migrant: Yes / No (Answer ‘Yes’ if family has moved within the past 36 months to obtain temporary or seasonal agricultural employment)
Citizenship: U.S. Citizen: Yes / No
If ‘No’, your Immigration Status:
Non-U.S. Citizen’s Country of Origin:
For non-U.S. citizens, provide the date the student(s) first entered a U.S. school:
. Does student receive ELL/ESL? Yes / No
Language first spoken by child:
Spoken at home by child:
Spoken at home by family:
Residential Parent(s)/Guardian(s): (Please indicate relationship to student)
Parent/Guardian Name:
Parent/Guardian Name:
Relationship to Student:
Relationship to Student:
Employer:
Employer:
City/State:
City/State:
Business Phone: (
)
Cell Phone (optional): (
Business Phone: (
)
)
Cell Phone (optional): (
Email address (optional):
)
Email address (optional):
Non-Residential Parent (if applicable):
Parent Name:
Relationship to Student:
Home Address:
City/State/Zip:
Phone: (
Does Parent have Joint Custody?
)
Yes
No
Other Members of Residential Household (please provide birthdates only if a child is preschool age):
Name:
Relationship:
D.O.B:
Name:
Relationship:
D.O.B:
Name:
Relationship:
D.O.B:
Last school attended (please list Pre-K/Nursery school/program for a first-time Kindergartner):
School Name:
Address:
Phone: (
City/State/Zip:
)
Fax:
Does student receive Special Services?
Last Grade Completed:
If ‘Yes’, does student have a current I.E.P?
Dates Attended:
or a current 504 Plan?
(Use reverse side if you need to list additional schools)
Register\Registration Form.doc 9/15
(Additional students, if needed, continued from front side)
Student(s) Full Legal Name - list only the students currently registering and the grade level they will enter:
Last Name:
First Name:
Middle Name:
Preferred Name / Nickname:
Grade:
Gender:
D.O.B:
Birthplace (city/state):
For high school students – school year student first entered Grade 9:
Last Name:
First Name:
Preferred Name / Nickname:
Grade:
Assigned Student ID:
Middle Name:
Gender:
D.O.B:
For high school students – school year student first entered Grade 9:
Birthplace (city/state):
Assigned Student ID:
(Additional school information, if needed, from front side)
Last school attended (please list Pre-K/Nursery school/program for a first-time Kindergartner):
School Name:
Address:
Phone: (
City/State/Zip:
)
Fax:
Does student receive Special Services?
Last Grade Completed:
Dates Attended:
If ‘Yes’, does student have a current I.E.P?
or a current 504 Plan?
Last school attended (please list Pre-K/Nursery school/program for a first-time Kindergartner):
School Name:
Address:
Phone: (
City/State/Zip:
)
Fax:
Does student receive Special Services?
Last Grade Completed:
Dates Attended:
If ‘Yes’, does student have a current I.E.P?
or a current 504 Plan?
DEFINITION OF ETHNICITY CATEGORIES
Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race
DEFINITION OF RACE CATEGORIES
American Indian/Alaskan Native – A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or community attachment
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand and Vietnam
Black/African American – A person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands
White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Federal Guidance Regarding Identification of Race/Ethnic Categories
Per federal guidelines, all students must be assigned to an ethnic and racial group for analysis purposes; therefore, all
children must be identified answering Yes or No to the ethnicity question, and by selecting one or more racial categories
provided above. In the case of elementary and secondary students, if a parent or guardian will not select a category,
appropriate school personnel should select a category for the student, based on observation.
Register\Registration Form.doc 9/15