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Kindergarten Enrollment and Verification of Residency Documentation

Welcome to the Essex Westford School District. We are very excited to have you join our educational family. Below you will find all the documents you need to register your student for school.

Ø You may submit electronically to Lorna Michaud, lmichaud@ewsd.org.Ø Please return the packet to any of the locations listed. If you have questions, contact Lorna at (802) 878-8168.Ø Families currently enrolled in a pre-K program that is receiving state funds/subsidy in our district do not need to supply birth certificate or

residency verification.We look forward to having your student be part of the Essex Westford School District!

District Offices East 58 Founders Rd.Essex, VT 05452 P: (802) 878-8168 or lmichaud@ewsd.org

Residency__(none required for children enrolled in a pre-K program receiving Act 166 funds)_____________ One (1) Proof of Residency from the following: • Current tax bill• Current mortgage papers/closing statement showing an address and the name of legal guardian• Formal lease showing the name, address, and telephone number of the landlord, address and name of lessee• *District may require or allow other proof of address if one of these is not available*

and Two (2) Proofs of Residency from the following*: • Valid Vermont driver’s license with local address or• Valid Vermont identification card with local address• Current utility bill or automobile insurance card in name of parent(s)/guardian/custodian with address• Bank statement for last or current month (financial information redacted)• *Additional documents that EWSD considers adequate proof of residency may be used*

Required Registration Forms________________________________________________________________

Need help?_________________________________________________________________________________________________

o Copy of birth certificate or other documents +o Copy of immunization recordso Three (3) forms of proof of residency +o Student Registration Form (pgs. 2-4)o Kindergarten Student Input Form (pgs. 5-7)o Yearly Student Health Information Form (Required)o At-Home Language Survey (Required)o Vermont Migratory Education Program (Required)o DCF-Placed/State-Placed Student Enrollment Form (if

applicable)

Please visit one of the school buildings at the addresses above if you need translation to your language. Si necesita ayuda con la traducción a su idioma, visite uno de los edificios escolares en las direcciones anteriores.

o Custodial agreements or court order (if applicable)o School Records Transfer Form

o Free and Reduced-Price Lunch Form. We ask all families to fillthis out if there is need, as several factors can help qualifychildren. Find online at ewsd.org/lunch or fill out online atmyschoolapps.com [Choose Vermont, and Essex WestfordSchool District.]

+ Residency not required if child is an Act 166 fund recipient inEssex or Westford

Additional Material:

Summit Street School (Essex Junction) 17 Summit Street Essex Junction, VT 05452 P: (802) 878-1377 | F: (802) 878-1380

Hiawatha Elementary School (Essex Junction ) 30 Hiawatha Avenue Essex Junction, VT 05452 P: (802) 878-1384 | F: (802) 879-8190

Essex Elementary School (Essex Town residents) 1 Bixby Hill Road Essex Junction, VT 05452 P: (802) 878-2584 | F: (802) 879-0602

Returning Forms Westford School (Westford residents) 146 Brookside Road Westford, VT 05494 P: (802) 878-5932 | F: (802) 879-0874 tmartin@ewsd.org

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Kindergarten Student Registration Form

Student Information

______________________________________ ___________________________ __________________ Student Last Name

Student Date of Birth

The following information is gathered for census purposes per the Vermont Agency of Education.

Yes Is the student Hispanic or Latino?

Student Gender

Race (check all that apply): American Indian or Alaskan Native

Asian Black or African American

White Native Hawaiian or Pacific Islander

____________________________

Does the student have a personally modified educational plan? Choose one of the following:

IEP Section 504 EST Plan Intervention ELL Other: __________________________ No

_______________ Grade Entering

____/____/____ Date of Enrollment

Name of Previous School

Previous School Address

_____________________________________________

____________________________________________ ____________________________________________

(___)_____________________

Last Name:

Student First Name

__________________________ __________

Student Middle Name

_____ / _____ /_____

Legal Name (if different) Nickname

Required Collection

____________________________________________

Student Information

Previous School PhonePrevious School Fax

Has the child attended an EWSD school in the past: Summit, Hiawatha, EES, Founders, Fleming, Westford, EMS, ADL, EHS or CTE?

Yes No

If yes, did the child have a different last name?

(___)_____________________

Optional: If student is from outside the U.S., country of citizenship: ____________________________________

If the student is placed by DCF or another licensed placement agency*, please specify:

Agency: _______________________ Case Manager: ___________________ Phone: (__ __ __) __ __ __-__ __ __ __

*__If the student is in Foster Care, a case manager must complete student registration. Fill out the DCF/State Placed Student

Enrollment form, found in the registration packet or at EWSD.org/newstudents.

Previous School Information (only if transferring m id-year)

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Parent/Guardian Information

Email: ___________________

Primary Phone: ___________________________

Work Phone ____________________________

Cell Phone _____________________________

Employer: _____________________________

Household-Sharing or Close Family Members

Names & Ages of Siblings:

__________________________ Age _______

_________________________ Age _______

_________________________ Age _______

__________________________ Age _______

____________________________Age _______

____________________________ Age _______

____________________________ Age _______

____________________________ Age _______

____________________________ Age _______Other adults acting as a caregiver or sharing home/s and relationship to the student (OR add as emergency contacts, next page):

___________________________________ _____________________________________________________

_________________________________________ Full Name

__________________________________________ Relationship to Student (mother, father, guardian, etc.)

Does student live with parent? Parent should receive mailings/emails? Is there a custody or care agreement in place? If care is shared, % of time with child _______*Please provide schools with any related court ordersand explain in the area below*

_____________________________________________Street Address (if mailing or P.O. Box please add on p.4)

City State ZIP code

Email: ___________________

Primary Phone: ___________________________

Work Phone ____________________________

Cell Phone _____________________________

Employer: _____________________________

___________________________ ________ _______________

City State ZIP code

___________________________________________ Full Name

___________________________________________ Relationship to Student (mother, father, guardian, etc.)

Does student live with parent? Parent should receive mailings/emails? Is there a custody /care agreement in place? If care is shared, % of time with child _______

____________________________________________________________ Street Address (if mailing or P.O. Box please add on p.4)

_____________________________ __________ ___________

Relationship

____________________________________________ Name

____________________________________________Name

_________________________________________________________________Relationship

Name

Relationship _______________________________________________________________

____________________________________________________________________________________________________________

Name Relationship

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Custody and/or Legal Restrictions

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

_________________________________________________________________________________________________Emergency Contacts

___________________

List three (3) adults who are authorized to make emergency decisions if the school is unable to contact you.

Contact 1

Name: ____________________________ Relationship_______________________

Phone 1 ___________________________ Type of Line - Cell/Work/House?

Phone 2 ___________________________ Type of Line - Cell/Work/House

___________________________________________________________________________________________________

Contact 2

Name: ____________________________ Relationship_______________________ Phone 1 ___________________________ Type of Line - Cell/Work/House?Phone 2 ___________________________ Type of Line - Cell/Work/House ______________________________________________________________________________________________ Contact 3

Name: ____________________________ Relationship_______________________ Phone 1 ___________________________ Type of Line - Cell/Work/House?Phone 2 ___________________________ Type of Line - Cell/Work/House _______________________________________________________________________________________________

Mailing Address (only complete this section if relevant)

Mailing Address (eg. PO Box): _________________________Address Line 2: _____________________________________City: ___________________________State/ZIP code: ______ _________________________

Please provide any court order(s) or other parental agreements relating to this student to the school's front office or turn in with this form.

Provide details in a summary below AND attach any court order or informal agreement :

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Kindergarten Student Input Form

____________________________ ________________________ ______________________________________ Student First Name Student Middle Name Student Last Name

________________________ ________________________ Parent Name Parent Name

Student Educational Background

The following information will be helpful in determining placement for your child in kindergarten:

At what age was your child first enrolled in a childcare or preschool program? _______

Starting with the first program your child attended, please fill past programs attended:

What was the name of the program or the provider?

In what town was it located? How many years did your child attend this program?

How many hours per week did your child attend this program?

May we have your permission to discuss your child with his/her previous caregivers or preschools? ___ Yes ___ No

Below are some general questions about your child.

Describe your child’s strengths:________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Describe your child’s temperament: (i.e. quiet, reserved, energetic, outgoing, etc…) ____________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________

Describe any special fears that your child has that the teacher should be aware of:______________________________ __________________________________________________________________________________________________

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What activities does your child enjoy doing at home? (games, toys, being read to, TV, looking at books, other) ____________________________________________________________________________________________________________________________________________________________________________________________________

What responsibilities does your child have at home? _______________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Have there been any significant experiences in your child’s life? (i.e. adoption, moves, illnesses, deaths, separations from family, divorce, etc…)____________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Are there any particular problems your child has which may affect his/her adjustment to school? __________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Which kind of discipline is the most helpful for your child? _________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have any dietary restrictions or food allergies? ______________________________________________ __________________________________________________________________________________________________

Do you think your child will need any special services? Is so please explain. ____________________________________ __________________________________________________________________________________________________ _____________________________________________________________________________________

What expectations do you have for your child’s kindergarten experience? __________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

What else would you like us to know about your child so that he/she may have a positive experience in kindergarten? ___________________________________________________________________________________________ ___________________________________________________________________________________________

Generally, your child: YES NO COMMENTS

Has regular playmates the same age?

Gets along with others?

Prefers to play with other children instead of alone? Effectively deals with frustration?

Cooperates with others?

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Generally, your child: YES NO COMMENTS

Is flexible with changes in routine?

Separates easily from parents?

Asks for help when needed?

Accepts discipline and limits?

Toilets independently?

Has healthy sleeping habits?

Sits to listen to a story?

Follows directions?

Stays with task for an extended period of time?

Follows daily routines?

Dresses himself/herself without assistance?

Are there any questions and/or areas in which you would like more information? _________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Would you like to speak to anyone in particular about your child? ____ Yes ____ No

___ Principal ___ School Nurse ___ School Counselor

___ Speech Pathologist ___ Other _____________________________________

If you would like to be contacted by one/or more of the people above, please list contact information below:

Name to contact: _________________________ Phone # ________________ Work Phone # ___________________

Thank you for this information. It will be shared with classroom teachers in order to help us provide a positive kindergarten experience for your child.

Yearly Health Information Form

Parent/Guardian signature__________________________________________________ Date_________

Hiawatha Elementary School | Summit Street School | Essex Elementary School | Thomas Fleming School | Founders Memorial School Albert D. Lawton Intermediate School | Essex Middle School | Essex High School | Center for Technology, Essex

Modified 2/5/18

Student Name:____________________________________ DOB (mm/dd/yyyy):____________ Grade:____ Gender:______

Best contact for illness or emergency Name:______________________ Phone: _____________________________________

Primary Physician:__________________________________ Physician’s Phone:_________________________________________

Dentist:__________________________________________ Dentist Phone:____________________________________________

Please list all Medical Conditions/Health Needs below (Attach additional pages if necessary)

Please list all Medications taken by the student below (Attach additional pages if necessary) Name Dosage Purpose

1.____________________________________________ 1.________________________ _______________ _____________

2.____________________________________________ 2.________________________ _______________ _____________

3. ___________________________________________ 3.________________________ _______________ _____________

4. ___________________________________________ 4.________________________ _______________ _____________

5. ___________________________________________ 5.________________________ _______________ _____________

6. ___________________________________________ 6.________________________ _______________ _____________ Note: A medication form signed by parent and physician is required for all prescription medications to be given at school

My child has permission to receive the following medications at school with dosage according to the weight/age of child: o Tylenol (acetaminophen) o Advil (ibuprofen)o Benadryl o Cough syrup

o AntacidPlease contact the school nurse if you wish to send in other over the counter medications for your student. The school nurses may use over the counter medication (e.g. antibiotic cream, anti-itch cream, cough drops) at their discretion. If you have objections to the use of these medications on your child, please contact the school nurse immediately.

Does student have medical insurance? o Yes o NoHas student had a dental checkup in the last year? o Yes o NoHas student had a well child/adolescent exam in the last year? o Yes o NoHas a doctor, nurse, or health professional EVER said that your child has asthma?

If yes, does your child STILL have asthma? o Yes o Yes

o Noo No

o Don’t knowo Don’t know

I authorize the school to contact my child’s healthcare provider for necessary medical information

o Yes o No

EMERGENCY CARE /TREATMENT: In the event of a serious injury or illness, emergency services will be called and parents contacted as soon as possible. If necessary, the student will be transported to the hospital for treatment.

If you have any questions about this form, please contact your school nurse.

Migrant Education Program

UVM Ext 327 US Route 302

Barre, Vermont 05641

(802) 476-2003 ext. 226 or

(866)-860-1382 ext. 226

Cultivating Healthy Communities University of Vermont Extension and U.S. Department of Agriculture, cooperating, offer education and employment to everyone without regard to race,

color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or familial status.

VERMONT EMPLOYMENT SURVEY

Please complete this form and return it to your school’s office. All information provided is confidential. The

Vermont Migrant Education Program will contact you to determine if your family is eligible. An eligible

student can be of any race and/or ethnicity and speak any language. Please call if you have any questions: 866-

860-1382 ext. 226

Guardian/Parent Name(s) ______________________________________________Date ________________

Address____________________________________________________Town__________________________

Cell phone(s)_____________________________________Land-line_____________________________

Please list all children ages 0 to 22 in your household: (list additional names on bottom of form)

Child: Grade: School:

Child: Grade: School:

Child: Grade: School:

Child: Grade: School:

Updated on 10.17.2019

Has your family moved from one town or state to another town or state in the last three years?

☐No, You do not need to complete the rest of this form. Thank you!

☐Yes, If yes from where? __________________________________ Please complete the rest of this form.

(town, city, state, country)

In the past three years, have you or anyone in your family worked in agriculture or logging? ______

If yes, please check all that apply:

☐Dairy Work;

☐Hemp;

☐Raising and tending to poultry including egg production;

☐Raising cows, pigs and other livestock or work in a slaughterhouse or other meat processing facility;

☐Planting, growing, harvesting, packing, cutting or preparing fruits, vegetables and flowers for sale;

☐Working in a greenhouse or nursery (tree/plant/flower) or planting, tending or harvesting field crops;

☐Working in the woods in logging, maple sugaring, planting trees, Christmas treeing, etc.;

☐Working in the catching, raising, harvesting or initial processing of fish or shellfish.

☐Other____________________________________________________________________________

Instructions for Home Language Survey (Revised: February 4, 2021)

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Appendix B: Home Language Survey

Dear Parent/Guardian(s):

Vermont welcomes families of all cultural and linguistic backgrounds. Speaking more than one language is a valuable asset for individuals, families, and communities. We encourage families to maintain their languages while learning English. In order to ensure meaningful communication between your family and our school, please let us know if you have questions and/or would like translation/interpreting services related to this survey or other important school notices. In order to meet challenging academic standards for all students, Federal law requires that public schools identify students who may be entitled to English language support services. Every parent/guardian of newly enrolling students in Kindergarten through grade 12 must complete the survey questions (below) at registration. An English Learner (EL) Specialist may request further information, if needed, to determine whether your student should be classified as an English Learner (EL) and is eligible to receive additional services.

Thanks very much for your time in completing this form! Please be assured that the survey information is used solely for educational purposes, to identify potential English Learners who might be eligible for English language support.

Student Information (Parents/Guardians should complete this section.) First Name:

Last Name:

Date of Birth (Month/Day/Year)

Gender:

F M

Country of Birth:

Date of Entry in U.S. (Month/Day/Year):

Date student first began Kindergarten (or higher grade) in any U.S. school (Month/Day/Year):

Questions for Parents/Guardians Response

1.What language(s) are spoken in your home?

2.What language do you most often speak to your child?

3.What language does your child currently use most often at home?

4.What is the native language of each parent/guardian?

5.What language did your child first speak or understand?

Instructions for Home Language Survey (Revised: February 4, 2021)

Page 5 of 5

For LEA Use Only: What school will the student attend?

What grade will the student enter?

Beginning date in this school (Month/Day/Year):

This student was screened for English Language Proficiency and identified as an English Learner (EL)?* Y / N Name of Test Administrator: Date Student Screened:

If not identified as an English Learner, does the student meet the ESSA Definition of “Immigrant Children and Youth”?* Y / N

Under ESSA, the term ‘immigrant children and youth’ means individuals who –

“(A) are aged 3 through 21;

“(B) were not born in any State (including Puerto Rico); and

“(C) have not been attending one or more schools in any one or more States for more than 3 full academic years.”

*LEAs should submit HLSs to the VT-AOE using the HLS collection site only for students who have been: 1.Screened by EL Professionals for English Language Proficiency and identified as ELs; and/or 2.Identified as eligible to be counted under the “Immigrant Children and Youth” definition.

58 Founders Road Essex Junction, VT 05452 ewsd.org (802) 878-8168

Attention Sending School: Please see box below for submission information. School Records Transfer Form

To whom it may concern,

According to the Final Regulation-Family Educational Rights and Privacy Act (Buckley Amendment), date June 17, 1976, it is no longer necessary to obtain written consent to release records between schools. It states that school officials, including teachers within the educational institution and officials of other schools in school systems in which the student may intend to enroll, may receive a student’s record without written consent for such release.

Please send records including: • Grades• Test Scores• Date of Last Attendance• Health Records• Special Education Records

• Any other pertinent information for the studentlisted below

• Psychological reports (if applicable)• Other special information

Thank you for your cooperation in this matter.

Student Name: _________________________________________ Date of Birth: _____/ _____/_____ Grade: _______________ Previous School: _________________________________________ Previous School Address: _________________________________________

_________________________________________ Previous School Phone: _________________________Previous School Fax: ____________________________

For School Use Only Please send information to the school checked below:

Hiawatha Elementary 30 Hiawatha Avenue Essex Junction, VT 05452 (802) 878-1384Fax: (802) 879-8190

Thomas Fleming 21 Prospect Street Essex Junction, VT 05452 (802) 878-1381Fax: (802) 879-5598

Albert D. Lawton 104 Maple Street Essex Junction, VT 05452 (802) 878-1388Fax: (802) 879-8175

Summit Street School 17 Summit Street Essex Junction, VT 05452 (802) 878-1377Fax: (802) 878-1380

Westford School 146 Brookside Road Westford, VT 05494 (802) 878-5932Fax (802) 879-0874

Essex Middle School 60 Founders Road Essex, VT 05452 (802) 879-7173Fax (802) 879-6139

Essex Elementary School 1 Bixby Hill Road Essex Junction, VT 05452 (802) 878-2584Fax (802) 879-0602

Founders Memorial School 33 Founders Road Essex, VT 05452 (802) 879-6326Fax (802) 879-6139

Essex High School Attn: Registrar2 Educational Drive Essex Junction, VT 05452 (802) 879-7121Fax (802) 879-5588

Note to Parents/Guardians: Fill out the below fields only. Return this request form with packet. Kindergarten parents: Only required for mid-year transfers.

Notes:

ESSEX WESTFORD SCHOOL DISTRICT DCF/STATE-PLACED STUDENT ENROLLMENT FORM

In addition to the New Student Enrollment Form, to be completed by the student’s legal guardian/custodian

STUDENT INFORMATION

Student full name: Student date of birth:

Student’s legal guardian/custodian’s full name:

Is this student in DCF custody? Yes* No *Please attach legal documentation pertaining to state placement

If YES: DCF District Office address:

Social Worker’s full name: Work phone number:

Is this student in the care of another child-placing agency? Yes No

If YES: Agency name & address:

Was a Best Interest Determination meeting held? Yes No

If YES: Date of BID meeting:

Does this child have an IEP? Yes* No *Please attach a copy of the student’s current IEP

If YES: Educational surrogate name: Phone number:

Mailing address:

RESIDENTIAL INFORMATION

Foster parent’s full name: Phone number:

Physical address (no PO Boxes, please):

City: State: ZIP Code:

PREVIOUS SCHOOL DISTRICT

If applicable, name of child’s previous school district:

Contact person: Phone number:

BIOLOGICAL PARENT INFORMATION

Biological mother’s full name: Biological father’s full name:

Physical address: Physical address:

City: City:

State: ZIP Code: State: ZIP Code:

SIGNATURE

Legal Guardian/Custodian: Date:

• facebook.com/essexwestford/• instagram.com/essexwestford/• twitter.com/EssexWestford

General

• District Calendar: ewsd.org/calendar• Parent-Student Handbook: ewsd.org/handbook• School Assignments and District Boundaries: ewsd.org/aboutus• School Pages/Start & Stop times: ewsd.org/schools

Child Nutrition Program

• Information on School Breakfast and Lunch: ewsd.org/lunch• Lunch Menus: ewsd.org/menus (also on school pages and in buildings)• Free and Reduced-Price Lunch: ewsd.org/freereduced• Accounts and payments: /lunchpayments• Summer Free Meals: ewsd.org/summerlunch

Transportation• Bus Stops and Times: ewsd.org/busfinder• Transportation News: ewsd.org/transportationSupport/Health Services• Translation and ELL Information: ewsd.org/ellprogram• Nurses' Information: ewsd.org/nurses• Student Support Services: ewsd.org/studentsupportsJoin Our Team!

• Job Openings at EWSD: ewsd.org/jobs

Follow us on Social Media!

EWSD District Information and Services

or Download the App at Google Play or the App Store

Scan this QR code or search for 'Essex Westford' to get the mobile app on your smartphone.

20-21 Teacher In-Service Days (no school)24-26 Teacher In-Service Days (no school)

8 First Day of Classes for Students

8 ParentTeacherConferences(AfterSchool)9 Parent Teacher Conferences (no school)12 Indigenous Day (no school)

3 Elections(noschool)23-24 Teacher In-Service Days (no school)25-27 Thanksgiving Break (no school)

23-31 Early Winter Break (no school)

1 Early Winter Break (no school)18 MLK Day (no school)

22-26 Winter Break (no school) 19 Parent Teacher Conferences (no school)

19-23 Spring Break (no school) 31 Memorial Day (no school)

14 Last Scheduled Day of School for Students* 15 Teacher In-Service Day (no school)

2020-2021 EWSD Calendar at a Glance

August

September

October

November

December

January

February

March

April

May

June

EssexWestfordSchoolDistrict58 Founders RoadEssexJunction,VT05452

Phone: 802.878.8168Website: www.ewsd.org

Social:@EssexWestford

*This is the last scheduled day for students if there are no cancellations due to weather/other

Updates on reopening and more for the 2020-2021 school year can be found at:

WWW.EWSD.ORG/2020-2021