New Student Registration Information Grades K-12...2. Enrollment Registration Requirements – (Form #2): Proof of Age – Original or Certified Copy of Child’s Birth Certificate

WEST MILFORD TOWNSHIP PUBLIC SCHOOLS

BOARD OF EDUCATION

46 HIGHLANDER DRIVE

WEST MILFORD, NEW JERSEY 07480

973-697-1700

www.wmtps.org

New Student Registration Information Grades K-12

Welcome to the West Milford Township Public School District. Our District is comprised of,

six (6) elementary schools, one (1) middle school and one (1) high school. The following is a

list of our schools, addresses and phone numbers:

West Milford High School (Grades 9 -12) Marshall Hill School (Grades K-6)

67 Highlander Drive 210 Marshall Hill Road

West Milford, NJ 07480 West Milford, NJ 07480

973-697-1701 973-728-3430

Macopin Middle School (Grades 7 & 8) Paradise Knoll School (Grades K-6)

70 Highlander Drive 103 Paradise Road

West Milford, NJ 07480 Oak Ridge, NJ 07438

973-697-5691 973-697-7142

Apshawa School (Grades K-6) Upper Greenwood Lake School (Grades K-6)

140 High Crest Drive 41 Henry Road

West Milford, NJ 07480 Hewitt, NJ 07421

973-838-6515 973-853-4466

Maple Road School (Grades K-6) Westbrook School (Grades K-6)

36 Maple Road 55 Nosenzo Pond Road

West Milford, NJ 07480 West Milford, NJ 07480

973-697-3606 973-697-5700

Registration packets for students K-12 are on the following pages. If you do not know which

school your child will be attending, please call the Transportation Department at 973-697-1700

ext. 7700 and they will be able to assist you.

Please follow the registration information process:

� Fill out the forms and gather your documentation to bring with you to registration.

� Call the school and schedule your registration appointment.

� Review the additional information for student programs that may interest you.

If you need additional information, please don’t hesitate to contact the Board Office at

973-697-1700 ext. 5000 for assistance.

1/2016


BOARD OF EDUCATION

46 HIGHLANDER DRIVE


973-697-1700

www.wmtps.org

KINDERGARTEN REGISTRATION CHECKLIST

REGISTRATION FOR STUDENTS TAKES PLACE AT THEIR HOME SCHOOL

PLEASE CALL FOR AN APPOINTMENT

Please complete all forms and bring them with you to your registration appointment. Your child will

not be considered registered until these documents are completed. If you do not know which school

your child will be attending, call our Transportation Department at 973-697-1700 ext. 7700 and they

can advise you of this information.

Registration Checklist

1. Student Registration - (Form #1)

2. Enrollment Registration Requirements – (Form #2):

Proof of Age – Original or Certified Copy of Child’s Birth Certificate or Passport

Proof of Residence - Any four (4) of the proofs of residence described in Groups A and B,

with the West Milford address shown on the student registration form.

Transfer Students Information – All other requirements for transfer students, as

applicable.

3. Domicile Information

School and Data Processing Tracking – (Form #3)

Proof of Domicile Acknowledgement – (Form #3A)

Preliminary: Parent/Guardian – (Form #3B)

4. Proof of Immunization: Documents Accepted as Evidence of Immunization which include the

following – (Form #4)

Health History - (Form #4A)

Acknowledgement of Physical Requirement – (Form #4B)

Student Physical Examination – (Form #4C)

Report of Dental Examination – (Form #4D)

Release of Medical Information Consent – (Form #4E)

5. Enrollment Information – (Form #5)

6. Emergency Information – (Form #6)

7. English as a Second Language/Home Language Survey – (Form #7)

8. Consent for Directory Information – (Form #8)

9. Student Acceptable Use Agreement & Consent Form – (Form #9)

http://www.wmtps.org/

NOTE: Please print clearly FORM #1

WEST MILFORD TOWNSHIP PUBLIC SCHOOLS STUDENT REGISTRATION FORM

SCHOOL ENTERING: STARTING DATE:______________ New Change Student Name: Government # ___________________

(Last) (First) (Middle) Student # ______________________

Cross Streets for Bus Stop:______________________________________________________________

Student Lives With: Parent(s) ( ) Guardian ( ) Marital Status: Married ___ Divorced ___ Widowed ___ Single__

_____________________ _______________ Parent to receive 2nd Report Card? Mother=s Full Name Maiden Name

_____________________________________ ____________________________________

or Guardian=s Full Name Father’s Full Name

_____________________________________ ____________________________________

Street Address or P.O. Box Address (if different)

_____________________________________ ____________________________________

City, State & Zip Code City, State & Zip Code

_____________________________________ ____________________________________

Home Telephone # Unlisted ( ) Home Telephone # Unlisted ( )

_____________________________________ ____________________________________

Cell # Cell #

_____________________________________ ____________________________________

E-mail Address E-mail Address

_____________________________________ ____________________________________

Occupation Occupation

______________________________________ ____________________________________

Employer Work Telephone # Employer Work Telephone #

Grade:____ Gender:_____ Birthdate:_____/_____/_____ Place of Birth:___________________________________ City State Ethnicity (Optional): White ( ) Black ( ) Hispanic ( ) American Indian ( ) Asian ( ) Pacific Islander ( ) American Citizen: Yes___ No___ Native Language:______________ Language Spoken at Home:________________ This information is not used to determine eligibility to attend school.

Sibling’s Name/Date of Birth: ________________________________ ___________________________________

________________________________ ___________________________________

Did your child attend pre-school (Kindergarten Only)? Yes ( ) No ( ) Has your child ever received any special services? Yes ( ) No ( ) TRANSFERRED FROM:_________________________________________ _______________________________

School Phone # _____________________________________________ _____________________________________________ Street Address & P.O. Box City, State & Zip Code I hereby certify that the above information is correct and true. I further certify that the address stated above is my legal and actual residence. Signature:________________________________________________ Date:_____________________________

Office Use Only: Date Records Sent For:_________________________________________

Original Entry/Re-entry Code:_________ Graduation Year:_____________ Teacher Name:_____________________ Homeroom:________________

Tuition Student Only: Resident District:______________________ Tuition:________________

Does your child have Health Insurance?

Yes - Name of Insurance Company:______________________________________________________________

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.

You may release my name and address to the NJ FamilyCare Program to contact me about health insurance.

Signature _____________________________ Printed Name ________________________ Date: ______________ Written consent required to release your name pursuant to 20 U.S.C. 1232g (b) (1) and 34 C.F.R. 99.30 (b)

List two neighbors or nearby relatives who will assume temporary care of your child. Name________________________________________

Home Address________________________________

Work Address________________________________

Telephone Home______________________________

Telephone Work______________________________

Cell Number__________________________________

Relationship__________________________________

Name_______________________________________

Home Address________________________________

Work Address_________________________________

Telephone Home______________________________

Telephone Work_______________________________

Cell Number__________________________________

Relationship__________________________________

Tf : revised 5/2013

FORM #2

Enrollment Registration Requirements

Proof of AgeA birth certificate or passport must be presented at the time of registration.

Proof of ResidenceGroup A: All persons coming to register children must bring four (4) proofs of residency. The registration process will not be initiated without ALL of the required documentation. Verification of a child’s residency requires the presentation from the list of the following documents with the West Milford address shown on the Student Registration form:

1. Homeowner – West Milford real estate tax bill, mortgage statement or signed Contract of Purchase.

2. Tenant – Lease; if residing as a tenant without a lease, a signed, notarized Sworn Statement of Tenancy (Affidavit) completed by the landlord.

3. Child is Domiciled with West Milford Resident Other than Parent – Affidavit Section Aexecuted by West Milford resident and Affidavit Section B executed by parent or guardian.

4. Child and Parent Living with West Milford Resident – Signed, notarized Sworn Statement of Residency (Affidavit) completed by the West Milford Resident and parent or guardian. (Affidavit provided upon request)

5. Child Placed in West Milford by Court – Court order placing child in home of West Milford resident.

6. Child Placed in West Milford by Child Welfare Agency – Document of child welfare agency ordering that child be placed in home of West Milford resident.

Group B: In addition, any of the following documents containing the West Milford address shown on the Student Registration form will also be accepted:

1. Driver’s license, vehicle registration and auto insurance card;2. Current utility bill;3. Current cable television bill;4. Current credit card bill;5. Written statement from realtor stating parent/guardian has signed a contract to purchase

or rent in West Milford;6. Official mail (bank statement, government correspondence, Internal Revenue, Division of

Taxation, Social Security Administration);7. Public assistance documents A.F.D.C. (Aid For Dependent Children) and W.I.C.

(Women, Infants and Children);8. Income tax return;9. Voter registration card/records;10. Unemployment benefits verification;11. Recent paycheck/stub;12. Documents to support Affidavit Sections A and B.

Transfer StudentsStudents transferring from NJ schools outside of West Milford must provide copy of their most recent report card and most recent standardized test results (where applicable). Submit an Original Transfer Card and/or appropriate materials. Complete Request Records form.

FORM #3

WEST MILFORD TOWNSHIP PUBLIC SCHOOLSPROOF OF RESIDENCY STATEMENT

SCHOOL & DATA PROCESSING TRACKING FORM

Parent Information

Mr/Mrs.: ____________________________________________________________________________

Address: ____________________________________________________________________________

Daytime Telephone #: HOME: (______)____________________WORK: (______)______________________

Ms./Mrs.: ___________________________________________________________________________

Address: ____________________________________________________________________________

Daytime Telephone #: HOME:(______)_____________________WORK: (______)______________________

-------------------------------------------------------------------------------------------------------------------------------

The student(s) residing with you at this address are: (Please list youngest to oldest; only include children currently attending West Milford Township Public Schools & the new student)

NAME(S) (Please PRINT) AGE GRADE SCHOOL ATTENDING

1.___________________________________________________________________________________

2.___________________________________________________________________________________

3.___________________________________________________________________________________

4.___________________________________________________________________________________

5.___________________________________________________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

School Use Only:

Please attach a copy of the completed residency section that applies to this student (i.e. Section A, B, C, or D). Do not include copies of proof of documentation.

Document completed and submitted by: __________________________________________________Signature

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -WHEN ALL DOCUMENTS ARE COMPLETED, PLEASE FORWARD TO LINDA CHINTALA AT THE BOE OFFICE

Data Services Entry Date: ________________________By: _________________________________

FORM #3A


PROOF OF DOMICILE ACKNOWLEDGEMENT

Student Name: _____________________________________

Dear Parent/Guardian:

The West Milford Board of Education has policies and procedures related to “Proof of Domicile” for students who attend our schools. The District shall only provide a free education to those students who are domiciled within the District or who otherwise qualify for a free education pursuant to the statutory and regulatory guidelines set forth in N.J.S.A. 18A:38-1 et seq. and N.J.A.C. 6A:22-1.1 et seq. A student shall be domiciled in the District “when he or she is living with a parent or legal guardian whose permanent home is located within the District.” N.J.A.C. 6A:22-3.1. The home is permanent if “the parent or guardian intends to return to it when absent and has no present intent of moving from it….” Id. If the District discovers that a student is attending school whose parents are not domiciled within the District and who is not otherwiseeligible for a free education, the District may apply for the student’s removal and seek tuition reimbursement for the period of ineligible attendance in accordance with the provisionsof N.J.S.A.18A:38-1(b) (2).

Applicants who fraudulently allow a child of another to use his residence, or who fraudulently claim to have custody of a child, may be charged with a disorderly persons offense. N.J.S.A. 18A:38-1 (c). If the applicant is convicted of such an offense, the applicant may be fined up to $1,000.00 and/or be imprisoned for up to 6 months.

Any false statements, answers or declarations contained in the Affidavit or in an application foradmission may subject the applicant to criminal prosecution for the crime of false swearing, in violation of N.J.S.A. 2C:43-3. If convicted for such a crime, the applicant may be punished by a fine of $10,000.00 and/or be imprisoned for up to 18 months.

I, the undersigned, hereby acknowledge that I have read and understood the contents of this notification.

_________________________________ ___________________Signature of Parent or Guardian Date

_________________________________Printed Name of Parent or Guardian

FORM #3B

PRELIMINARY INFORMATION: PARENT/GUARDIAN, PLEASE READ BEFORE

PROCEEDING

The questions asked in the following pages will enable us to determine your student’s eligibility to attend school in this district in accordance with New Jersey law. Please be aware that N.J.S.A. 18A:38-1 and N.J.A.C. 6A:22 require that a free public education be provided to students between the ages of 5 and 20, and to certain students under 5 and over 20 as specified in other applicable law, who are:

∑ Domiciled in the district, i.e., the child of a parent or guardian, or an adult student, whose permanent home is located within the district. A home is permanent when the parent, guardian or adult student intends to return to it when absent and has no present intent of moving from it, notwithstanding the existence of homes or residences elsewhere

∑ Living with a person, other than the parent or guardian, who is domiciled in the district and is supporting the student without compensation, as if the student were his or her own child, because the parent cannot support the child due to family or economic hardship

∑ Living with a person domiciled in the district, other than the parent or guardian, where the parent/guardian is a member of the New Jersey National Guard or the reserve component of the U.S. armed forces and has been ordered into active military service in the U.S. armed forces in time of war or national emergency

∑ Living with a parent or guardian who is temporarily residing in the district

∑ The child of a parent or guardian who moves to another district as the result of being homeless

∑ Placed in the home of a district resident by court order pursuant to N.J.S.A. 18A:38-2

∑ The child of a parent or guardian who previously resided in the district but is a member of the New Jersey National Guard or the United States reserves and has been ordered to active service in time of war or national emergency, resulting in relocation of the student, pursuant to N.J.S.A. 18A:38-3(b)

∑ Residing on federal property within the State pursuant to N.J.S.A. 18A:38-7.7 et seq.

Note that “guardian” means a person to whom a court of competent jurisdiction has awarded guardianship or custody of a child, provided that a residential custody order shall entitle a child to attend school in the residential custodian’s school district subject to a rebuttable presumption that the child is actually living with such custodian; it also means the Department of Children and Families for purposes of N.J.S.A. 18A:38-1(e). Also note that a student is entitled to attend school in the district of domicile notwithstanding that the student is qualified to attend school in a different district as an “affidavit” student or temporary resident.

Note that the following do not affect a student’s eligibility to enroll in school:

∑ Physical condition of housing or compliance with local housing ordinances or terms of lease

∑ Immigration/visa status, except for students holding or seeking a visa (F-1) issued specifically for the purpose of limited study on a tuition basis in a United States public secondary school

∑ Absence of a certified copy of birth certificate or other proof of a student’s identity, although these must be provided within 30 days of initial enrollment pursuant to N.J.S.A. 18A: 36-25.1

∑ Absence of student medical information, although actual attendance at school may be deferred as necessary in compliance with rules regarding immunization of students, N.J.A.C. 8:57-4.1 et seq.

∑ Absence of a student’s prior educational record, although the initial educational placement of the student may be subject to revision upon receipt of records or further assessment by the district

The following forms of documentation may demonstrate a student’s eligibility for enrollment in the district. Particular documentation necessary to demonstrate eligibility under specific provisions in law will be indicated in the appropriate section of the registration form.

∑ Property tax bills, deeds, contracts of sale, leases, mortgages, signed letters from landlords and other evidence of property ownership, tenancy or residency

∑ Voter registrations, licenses, permits, financial account information, utility bills, delivery receipts, and other evidence of personal attachment to a particular location

∑ Court orders, State agency agreements and other evidence of court or agency placements or directives

∑ Receipts, bills, cancelled checks and other evidence of expenditures demonstrating personal attachment to a particular location, or, where applicable, to support of the student

∑ Medical reports, counselor or social worker assessments, employment documents, benefit statements, and other evidence of circumstances demonstrating, where applicable, family or economic hardship, or temporary residency

∑ Affidavits, certifications and sworn attestations pertaining to statutory criteria for school attendance, from the parent, guardian, person keeping an “affidavit student,” adult student, person(s) with whom a family is living, or others as appropriate

∑ Documents pertaining to military status and assignment

∑ Any business record or document issued by a governmental entity

∑ Any other form of documentation relevant to demonstrating entitlement to attend school

The totality of information and documentation you offer will be considered in evaluating an application, and, unless expressly required by law, the student will not be denied enrollment based on your inability to provide certain form(s) of documentation where other acceptable evidence is presented.

You will not be asked for any information or document protected from disclosure by law, or pertaining to criteria which are not legitimate bases for determining eligibility to attend school. You may voluntarily disclose any document or information you believe will help establish that the student meets the requirements of law for entitlement to attend school in the district, but we may not, directly or indirectly, require or request:

∑ Income tax returns

∑ Documentation/information relating to citizenship or immigration/visa status, unless the student holds or is applying for an F-1 visa

∑ Documentation/information relating to compliance with local housing ordinances or conditions of tenancy

∑ Social security numbers

Please be aware that any initial determination of the student’s eligibility to attend school in this district is subject to more thorough review and subsequent re-evaluation, and that tuition may be assessed in the event that an initially admitted student is later found ineligible. If your student is found ineligible, now or later, you will be provided the reasons for our decision and instructions on how to appeal.

If you experience difficulties with the enrollment process, please see your school’s secretary for assistance.

To the Person Enrolling the Student: Please complete the appropriate section A, B, C or D below, according to the situation best matching the student’s circumstances:

Complete SECTION A (DOMICILE) if the student is the child of a parent or guardian, or an adult student, whose permanent home is the address given on page 1 of this application and is located in the district.

or

Complete SECTION B (“AFFIDAVIT” STUDENT) if the student is living with a person domiciled in the district, other than the parent or guardian.

or

Complete SECTION C (TEMPORARY RESIDENT) if the student is living with a parent or guardian temporarily residing within the district.

or

Complete SECTION D (SPECIAL CIRCUMSTANCES) if the student’s situation is not addressed by Section A, B or C or if any of the circumstances in Section D apply.

SECTION A (DOMICILE): Complete this section if the student is the child of a parent or guardian, or an adult student, whose permanent home is the address given on page 1 of this application and is located in the district. If you are the student’s guardian, or will be the guardian of a student from out of state following expiration of the required 6-month waiting period, you will be asked to provide official papers proving guardianship. You will not be asked to produce “affidavit student” proofs of the type requested in Section B below.

How long have you lived in this home?

Do you have any present intention of moving from this home? If so, when and to where?

Do you have residence(s) elsewhere, and, if so, where are they and when do you live there?

Please list four forms of proof (see attached list) you will provide to demonstrate that the address given on page 1 of this application is your permanent home.

1.

2.

3.

4.

(Continued on Next Page)

SECTION A (DOMICILE) CONTINUED:

If the student’s parents are domiciled in different districts, regardless of which parent has custody, please answer the following questions:

Is there a court order or written agreement between the parents designating the district for school attendance, and if so, where does it require the student to attend school? (You will be asked to provide a copy of this document.)

Does the student reside with one parent for the entire year? If so, with which parent and at what

address?

If not, for what portion of time does the student reside with each parent and at what addresses?

If the student lives with both parents on an equal-time, alternating week/month or other similar basis, with which parent did the student reside on the last school day prior to October 16 preceding the date of this application?

Please note: No district is required, as a result of being the district of domicile for school attendance purposes where a student lives with more than one parent, to provide transportation for a student residing outside the district for part of the school year, other than transportation based upon the home of the parent domiciled within the district to the extent required by law.

If you are claiming to be an emancipated student, are you living independently in your own permanent home in the district? If yes, please describe the proofs you will provide, in addition to those demonstrating domicile, to demonstrate that you are not in the care and custody of a parent or guardian. ___

Please note: Under New Jersey law, where a dwelling is located within two or more local school districts, or bears a mailing address that does not reflect the dwelling’s physical location within a municipality, the district of domicile for school attendance purposes is that of the municipality to which the resident pays the majority of his or her property tax, or to which the majority of property tax for the dwelling in question is paid by the owner of a multi-unit dwelling.

END OF SECTION A

SECTION B (“AFFIDAVIT” STUDENT): Complete this section if the student is living with a person domiciled in the district, other than the parent or guardian.

Is the person domiciled in the district, supporting the student without remuneration as if the student were his or her own child, keeping the student for a longer time than the school term and assuming all personal obligations for the student relative to school requirements? Please explain. (You will be asked to file a sworn statement, along with a copy of the person’s lease if a tenant, or a sworn landlord’s statement if a tenant without written lease.)

Students are not eligible to attend school as “affidavit” students unless the student’s parent or guardian is not capable of supporting or providing care for the student due to family or economic hardship, and unless it is clear that the student is not living in the district solely for purposes of receiving a public education there. Please explain the circumstances applicable in this case, with special attention to the parent/guardian’s family and/or economic hardship. (The parent/guardian will be required to file a sworn statement with documentation to support the claims made.)

Please note: A student will not be considered ineligible because required sworn statements(s) cannot be obtained, so long as evidence is presented that the underlying requirements of the law are being met.

A student will not be considered ineligible when evidence is presented that the student has no home or possibility of school attendance other than with a non-parent district resident who is acting as the sole caretaker and supporter of the student.

A student will not be considered ineligible solely because a parent or guardian provides gifts or limited contributions, financial or otherwise, toward the welfare of the student, provided that the resident keeping the student receives no payment or other remuneration from the parent or guardian for the student’s actual housing and support. Receipt by the resident of social security or other similar benefits on behalf of the student do not render a student ineligible.

It is not necessary that guardianship or custody be obtained before a student will be considered for enrollment on an “affidavit” basis.

END OF SECTION B

SECTION C (TEMPORARY RESIDENT): Complete this section if the student is living with a parent or guardian temporarily residing within the district, even if the parent has a domicile elsewhere.

How long have you lived in this residence?

Do you have a domicile or residence(s) elsewhere, and, if so, where are they and when do you

live there?

Please list four forms of proof (see attached list) you will provide to demonstrate that you are residing at the address given on page 1 of this application, and that such residence is not solely for the purpose of the student attending school in the district.

1.

2.

3.

4.

Please note: Under New Jersey law, where a dwelling is located within two or more local school districts, or bears a mailing address that does not reflect the dwelling’s physical location within a municipality, the district of domicile for school attendance purposes is that of the municipality to which the resident pays the majority of his or her property tax, or to which the majority of property tax for the dwelling in question is paid by the owner of a multi-unit dwelling.

If the student’s parents are domiciled in different districts, regardless of which parent has custody, please answer the following questions:

Is there a court order or written agreement between the parents designating the district for school attendance, and if so, where does it require the student to attend school? (You will be asked to provide a copy of this document.)

Does the student reside with one parent for the entire year? If so, with which parent and at what

address?

If not, for what portion of time does the student reside with each parent and at what addresses?

(Continued on Next Page)

SECTION C (TEMPORARY RESIDENT) CONTINUED:

If the student lives with both parents on an equal-time, alternating week/month or other similar basis, with which parent did the student reside on the last school day prior to October 16 preceding the date of this application?

Please note: No district is required, as a result of being the district of temporary residence for school attendance purposes where a student lives with more than one parent, to provide transportation for a student residing outside the district for part of the school year, other than transportation based upon the home of the parent residing within the district to the extent required by law.

END OF SECTION C

SECTION D (SPECIAL CIRCUMSTANCES): Please indicate if any of the following apply.

The student is the child of a parent or guardian who has moved to another district as the result of being homeless.

The student has been placed in the home of a district resident other than the parent or guardian by court order. (You will be required to provide a copy of the order.)

The student has been placed in the district by the Department of Children and Families acting as the student’s guardian.

The student is a child of a parent or guardian who previously resided in the district and is a member of the New Jersey National Guard or the United States reserves ordered to active service in time of war or national emergency, resulting in relocation of the student.

The student is kept in the home of a person domiciled in the district, other than the parent or guardian, and the parent/guardian a member of the New Jersey National Guard or the reserve component of the United States armed forces and has been ordered into active military service in the United States armed forces in time of war or national emergency. If this applies, when is the parent or guardian expected to return from active military duty?

The student resides on federal property? Where?

______The student’s circumstances do not appear to be addressed anywhere in this application. I understand that I will be contacted by the Superintendent of Schools for further information.

END OF SECTION D

If you experience difficulties with the enrollment process, please see your school secretary for assistance.

FORM #4

PROOF OF IMMUNIZATION: DOCUMENTS ACCEPTED AS EVIDENCE OF IMMUNIZATION

The following documents will be accepted as evidence of a pupil’s immunization history provided that the individual immunizations and the date when each immunization was administered are listed:

1. An official school record from any school indicating compliance with the immunizationrequirements listed below.

2. A record from any public health department indicating compliance with the immunizationrequirements listed below.

3. A certificate signed by a physician licensed to practice medicine, osteopathy, or a certifiednurse practitioner in any jurisdiction in the United States indicating compliance with the immunization requirements listed below.

Medical ExemptionsA medical exemption is acceptable from a licensed M.D. or D.O. or Certified Nurse Practitioner or PA. Medical exemptions must be submitted and reviewed annually. A medical exemption is acceptable if it is based upon a valid medical contradiction according to the American Academy of Pediatrics standards.

Religious ExemptionsA parent/guardian may request a religious exemption by submitting a written statement to the Board, which explains how to the administration of immunizing agents conflicts with the pupil’s exercise of religious tenets and practices. These letters will be reviewed by the West Milford Board of Education. New Jersey legislation does not recognize philosophical or moral objections as reasons for securing a religious exemption.

Exceptions for Students Listed AboveTuberculin skin testing is not required if the student has attended school in another state prior to entering the New Jersey school system.

Students entering a U.S. school for the first time in New Jersey or transferring into a New Jersey school from another country must receive an IGRA or Mantoux Tuberculin skin test unless they are entering from the list of countries which have a low incidence of TB and require no TB testing. This list can be obtained from the School Nurse’s Office.

Any student with parents claiming religious exemption cannot be compelled to submit to tuberculin skin testing. In these instances, a symptom assessment must be done. If TB-like symptoms are reported, a physician must document that the student does not have an active disease. Each school district is responsible for determining the criteria essential to document a valid religious exemption.

Please notify the school nurse at registration if your child has Food Allergies/Asthma/EPI-Pen or other health issues.

FORM #4A

WEST MILFORD TOWNSHIP PUBLIC SCHOOLSHEALTH HISTORY FORM

School _____________________________________ Grade _______________

Pupil’s Name __________________________ ___________________ __________________Last First Middle

Sex ________ Birth Date _______________ Birth Place _____________________________

Address _____________________________________________ Telephone ________________

Father’s Name _________________________ Mother’s Name ___________________________

Brothers _____Sisters ______ This child is our 1st___ 2nd___3rd___4th___ child in our family.

1. With whom does your child live? _____________________________________________

2. When was your child’s most recent physical examination? ___________________________Date

Name of Physician/Clinic ____________________________________________________________

Purpose of examination: Routine check up ______ Illness/Injury (Specify)______________

3. Please check if your child has had any of the following conditions. Note date of diagnosis and/or occurrence.

Accidents/Injuries ____________________; Anemia ________; Autism _____________;

Allergies: Food __________; Insect Stings _______ Latex ______ Other ______________;

Asthma ___ Uses Inhaler ___ Last Asthma Episode______; Behavior Problem: _________;

Chicken Pox ________; Congenital Defect _________________; Diabetes ____________;

Drug Sensitivities_____________________; Ear infections ______________________;

Hearing Loss________; Heart Condition:_____________: Lead Poisoning ____________;

Seizures/Convulsions _________; Sickle Cell Anemia _______; Speech Deficit _________;

Strep Infections _______________; Surgery _____________________________________;

Vision ______; Corrective Lenses______; Patching______

Explain:____________________________________________________________________

___________________________________________________________________________

4. Are there any foods your child must avoid (special diet, food intolerances, religious reasons)?

___________________________________________________________________________

5. Does your child take medication(s)? ______Name of medication(s)_____________________

6. Has your child been hospitalized for any reason since birth? Yes _____ No _____

If yes, note date and reason:_____________________________________________________ Page 1

7. During the pregnancy with this child:a) Did the mother have any medical problems (e.g., high blood pressure, gestational

diabetes, exposure to infections)?

Specify:_________________________________________________________________

b) Did the mother smoke cigarettes? If yes, note amount_____________________________

c) Drink alcohol? If yes, note amount ____________________

d) Take any drugs/medication other than vitamins? If yes, give names and frequency.

________________________________________________________________________

8. Were there any problems during labor and delivery? Yes _____ No _____

Comments:________________________________________ Birth Weight ____lbs.____ozs.

Did your child leave the hospital when his/her mother left? Yes _____ No _____

How long did your child remain in the hospital after birth?___________________________

9. What age did your child: Walk alone? __________; Talk? (2 words together) __________;

Daytime toilet trained? ________________: Bed-wetting a problem? Yes ____ No _____

10. Do any close relatives in your family have a history of: (indicate relationship to child)

Anemia ______________ Birth Defect_______________ Cancer __________________

Diabetes______________ Heart Disease_____________ High Blood Pressure __________

Learning Problems __________________ Mental Illness_________________

Seizures/Epilepsy___________ Sickle Cell Anemia ________ Thyroid Condition ________

Other_____________________________________________________________________

11. Are there any problems in the home that might affect your child’s learning? Yes ___ No___

Comment:_________________________________________________________________

12. Is there anything more about your child’s health that you think is important for us to know?

Explain: __________________________________________________________________

__________________________________________________ _______________________Parent’s/Guardian’s Signature Date

__________________________________________________ _______________________Nurse’s Signature Date

Page 2

ep11/10/10

FORM #4B

WEST MILFORD TOWNSHIP PUBLIC SCHOOLSBOARD OF EDUCATION46 HIGHLANDER DRIVE

WEST MILFORD, NJ 07480

Printed Name of Parent/Guardian:__________________________________

ACKNOWLEDGEMENT OF PHYSICAL REQUIREMENT

Date: ____________

Dear Parent/Guardian:

New Jersey Law mandates that every student entering a New Jersey public school, regardless of the transferring locations, must present a physical exam signed by a licensed physician. The physical must have been completed within 365 days prior to the student’s registration in West Milford, and it is due in the nurse’s office within 30 days of registration. Please make sure you provide the nurse with a written exam report as soon as possible. Your signature below indicates that you have been informed of this policy.

Thank you for your cooperation and attention to this matter.

West Milford Township Public Schools

__________________________________________Parent/Guardian Signature

WEST MILFORD TOWNSHIP PUBLIC SCHOOLS FORM #4CSTUDENT PHYSICAL EXAMINATION

Date of Exam______________

NAME__________________________________________ BIRTH DATE____________GRADE________SEX M______F_______

ADDRESS____________________________________________________________ HEIGHT_________ WEIGHT___________

EARS_________________ EYES________________ LYMPH GLANDS________________ THYROID___________________

NOSE_________________ THROAT________________ TEETH/MOUTH_________________ HEART____________________

LUNGS_______________________ ABDOMEN___________________ HERNIA ______________

GENITO-URINARY__________________ SPINE/SCOLIOSIS_____________________ FEET/POSTURE___________________

SKIN________________ NUTRITION_______________ NERVOUS SYSTEM________________ SPEECH ________________

OTHER_____________________________________ GENERAL APPEARANCE_____________________________________

BP _______________ HEARING R__________ L__________ VISION R____________L_____________

**CODE: N-Normal X-Needs Attention Please circle the appropriate vaccine and types given below forthe DPT and Polio sections. It is required by the NJDOH.

PAST HISTORY IMMUNIZATION RECORDDISEASE AGE DATES (Month/Day/Year)

VACCINE (cirlcle one) Date GivenChicken Pox DT DTP Dtap 1German Measles DT DTP Dtap 2Measles DT DTP Dtap 3Mumps DT DTP Dtap 4Strep Infections DT DTP Dtap 5MRSA TDAP

Pneumonia OPV IPV 1

Asthma OPV IPV 2Tuberculosis or Contact OPV IPV 3Otitis Media OPV IPV 4Heart Disease MMR 1Epilepsy/Seizure Disorder MMR 2

Congenital Defect HIB 1Rheumatic Fever HIB 2Lyme Disease HIB 3Lead Poisoning HIB 4Allergies: Foods HEP B 1

Pollen, Grass, Weeds, etc. HEP B 2

Medications HEP B 3Injuries: VARICELLA 1

VARICELLA 2Surgery: PNEUMOCOCCAL CONJUGATE

INFLUENZAHospitalizations: MENIMUNE MENACTRA

GARDISILComments: HEP A 1

HEP A 2

Mantoux/TB Test Physician's Signature___________________________Date Adm. ______________ Results:____________ Phone No.:___________________________________

Date:________________________________________Print or Stamp M.D. name:

NEW STUDENT PHYSICAL AND IMMUNIZATIONS MUST BE UP-TO-DATE,COMPLETED AND SUBMITTED PRIOR TO SCHOOL ENTRY.

Revised 1/2014

FORM #4D

West Milford Township Public Schools

Good oral health care for your child is an investment in his/her health that will pay lifelong dividends. Regular dental check-ups are an important part of proper oral care. Please have your child’s dentist complete this form and return it to the health office.

Report of Dental Examination

Date: _________________

Student’s Name _____________________________________ Age ___________

Grade/Teacher _____________________________

Results of Dental Examination

_____ All necessary dental care has been rendered

_____ The child is receiving dental treatment

Comments ____________________________________________________________________

Date of next dental visit recommended _____________________

Signature of Dentist ___________________________________

Dentist’s Printed Name and Address Stamp

Dentist’s Telephone No. _____________________________________

FORM #4E

WEST MILFORD TOWNSHIP PUBLIC SCHOOLSBOARD OF EDUCATION46 HIGHLANDER DRIVE


RELEASE OF MEDICAL INFORMATION CONSENT FORM

Student’s Name: ________________________________________(Please Print)

Parent/Legal Guardian Name: ______________________________(Please Print)

Please Check One:

_____ I authorize the West Milford Township School Nurses to disclose to the West Milford Township School district employees (i.e., faculty, staff, coaches and volunteers), on a need-to-know basis, medical information from my child’s health record (i.e., known medical conditions, allergies, medications).

_____ I do not authorize the West Milford Township School Nurses to disclose information from my child’s health record to West Milford School District employees, except when medically necessary. By checking this box, I take full responsibility to disclose said information to District employees and further, I agree to voluntarily release, indemnify, defend and hold harmless the West Milford Board of Education, collectively and individually, as well as its agents, servants, employees and volunteers, from any and all claims which may be brought individually by my/our child or on our/their behalf now and forever, arising out of or connected with, either directly or indirectly, my child’s known medical issues, allergies or related emergencies, including medication reactions, caused by any employee or agent’s negligence or lack of knowledge related to my child’s medical condition.

Parent/Legal Guardian Signature: __________________________________________

Date: ______________

This consent to disclose information will be valid during your student’s entire period of enrollment in the West Milford Township Public Schools. It is your responsibility to update this information annually (i.e., via Emergency Forms) and whenever the student’s medical condition/information changes.

WEST MILFORD TOWNSHIP SCHOOLS FORM #5

ENROLLMENT INFORMATION FORM

In order to provide your child with the best possible program of studies, we ask that you complete the following: The more you tell us the better we will be able to service your child.

Student's Name________________________________________ Entering Grade: _______

A. Has your child participated in any of the following programs?YES NO

1. Resource Center or Special Education Classes ____ ____

2. Title I, Encore or ResourceReading ____ _____

Math ____ _____

3. Speech Therapy _____ _____

4. Gifted and Talented Program _____ _____

5. Honors or Advanced Level Programs _____ _____

6. Instrumental or Vocal Music Program _____ _____

B. Has your child ever had a 504 Plan or IEP written for him/her, or participated in a special learning program not shown above? If so, please explain.

C. Are there any special custody regulations regarding your child? If so, please explain. Please be advised that a copy of court custody or restraining orders must be on file at the school in order to deny a natural parent access to their child.

WEST MILFORD TOWNSHIP PUBLIC SCHOOLS Emergency Information Form

2016 - 2017 School Year

Dear Parent or Guardian: To serve your child in case of sudden illness, it is necessary to provide the following information for emergency

purposes. Please correct any outdated information and complete all missing information. Write “N/A” if the area is not applicable or

information is not available. Sign and return to the main office. This form will eliminate the need to complete multiple emergency cards.

ID#

Last Name: First: Middle: DOB:

Address: School:

City: Grade:

Home Telephone: Teacher/H.R.:

Name Address Telephone Cell

Mother: Home:

Workplace:

Father: Home:

Workplace:

E-mail Address:

List two neighbors or nearby relatives who will assume temporary care of your child.

Name Name

Home Address Home Address

Work Address Work Address

Telephone Home Telephone Home

Telephone Work Telephone Work

Cell Number Cell Number

Relationship Relationship

Does child have Health Insurance? Yes _____ No______ Has Health Insurance Changed? Yes_____ No _____Yes If Yes, name of Insurance Company:

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

You may release my name address to the NJ FamilyCare Program to contact me about health insurance.

Signature________________________________ Printed Name:_______________________________ Date:_____________ Written consent required to release your name pursuant to 20 U.S.C 1232g (b)(1) and 34 C.F.R 99.30(b)

List any medical/surgical care your child has received during the past year. Y N

Does your child attend daycare? Yes No if Yes, Where Braces:

List Medical Conditions: Glasses:

Medications (taken @ home and school): Hearing Aides:

List Allergic / Reactions:

List Medical Restrictions:

I agree to have my child screened for scoliosis? For Grades 5-12 (Please initial) _______

Name Telephone Sibling Name School Attending

Doctor:

Hospital:

I, the undersigned, do hereby authorize officials of New Jersey Public Schools to contact directly the persons named on this card and do

authorize the named physicians to render such treatment as may be deemed necessary in an emergency, for the health of said child.

In the event that physicians, other persons named on this card, or parents cannot be contacted, the school officials are hereby authorized to take

whatever action is deemed necessary in their judgment, for the health of the aforesaid child.

I will not hold the school district financially responsible for the emergency care and/or transportation for said child.

Signature: ____________________________________________________Date:_______________________

FORM #7

WEST MILFORD TOWNSHIP PUBLIC SCHOOLSENGLISH AS A SECOND LANGUAGE PROGRAM

HOME LANGUAGE SURVEY

As required by State and Federal Law (NJ: Bilingual Education Act of 1975; U.S. Lau vs. Nichols Supreme Court ruling of 1974), all parents must be surveyed as to the home language of their public school children. The results of the survey will be used to provide an appropriate educational program for your child.

This form must be returned with other registration materials.

Student’s Name ________________________________________________________________________

Address ______________________________________________________________________________

School _____________________________________ Grade ___________ Date __________________

Telephone Number _____________________________________________________________________

1. What is your child’s native language (the language he/she first learned to speak)?__________________________________________________________________________________

2. List the languages spoken at home?______________________________________________________

3. What language do you use most often when speaking to your child at home?__________________________________________________________________________________

4. What language does your child use most often when speaking to you, his parents at home?___________________________________________________________________________________

5. What language does your child use most often when speaking to brothers and sisters?__________________________________________________________________________________

6. What language does your child use most often when speaking to other relatives?__________________________________________________________________________________

7. What language does your child use most often when speaking to friends at home?__________________________________________________________________________________

8. Did your child previously receive ESL or bilingual instruction? Yes __________ No __________If yes, when? ___________________________________ Where? __________________________

Thank you for your cooperation.

Please Sign __________________________________________________________________________

For any responses containing a language other than English:Original – School Filec: Data Services

ESL Teacher

1/2014

FORM #8


CONSENT FORM FOR DIRECTORY INFORMATION

ó We are sending you this parental consent form to both inform you and to request permission for your child’s photo/image and personally identifiable information to be published on the district and/or school’s web site, newsletter or press release.

ó From time to time, we seek to recognize your child and his/her work or achievements in the District. Pursuant to law and Board of Education Policy, the Board is permitted to release certain personally identifiable information towards this goal, classified as “directory information,” without prior written consent from a student’s parent or guardian, unless the parent or guardian prohibits such release. Directory information includes student names, residential addresses, telephone numbers, sports in which the student participates and related information, and other similarly non-intrusive information. Directory information will never include information relating to your child’s education or class performance.

Please check one of the following:

ó □ I/We GRANT permission for the below-named student’s directory information to be released by the District pursuant to law, published on the school/district Internet site, school/district newsletter, press release, or other appropriate forum, as determined by the Board of Education and/or its agents and employees.

ó □ I/We GRANT permission for the following information only to be released by the District, as appropriate (check all that apply):

□ Name □ Address □ Telephone Listing □ Photograph/Image □ Date of Birth □ Place of Birth □ Class Standing (e.g. sophomore) □ Dates of Attendance □ Athletic Participation □ Awards and Honors Received

ó □ I/We DO NOT GRANT permission for any directory information that includes this student to be published on the school/district Internet site, newsletter and/or press release, without my prior written consent.

Student’s Name: ________________________________________

Parent/Guardian Signature: ________________________________

Date: _______________

FORM # 9


Student Acceptable Use Agreement and Consent Form

Student Section

Student Name: ____________________________________________Grade: ___________

School: _________________________________________________________________

My parents & I have read the “Acceptable Use of Computer Network/Computers and Resources" (Policy

# 2361), the “Pupil Discipline/Code of Conduct" (Policy # 5600), and the "Pupil Discipline/Code of

Conduct" (Regulations 5600-5600.2). I agree to be a responsible cybercitizen and to follow my school’s

rules for the use of technology. I understand that if I violate the rules my account can be terminated and I

may face other disciplinary measures.

Student Signature_________________________________________Date____________

Parent / Guardian Section

I have read the “Acceptable Use of Computer Network/Computers and Resources"(Policy # 2361), the

“Pupil Discipline/Code of Conduct" (Policy # 5600), and the "Pupil Discipline/Code of Conduct "

(Regulations 5600-5600.2).

I hereby release the district, its personnel, and any institutions with which it is affiliated, from any and all

claims and damages of any nature arising from my child’s use of, or inability to use, the District

Technology system, including but not limited to claims that may arise from the unauthorized use of the

system to purchase products or services.

I will instruct my child regarding any restrictions against accessing material that fall outside of the

District’s Technology Acceptable Use Policy #2361. I will emphasize to my child the importance of the

safe and responsible use of technology.

I give permission to issue an account for my child and certify that the information contained in this form

is correct.

Parent/Guardian Signature: ___________________________________Date____________

Parent/Guardian Name: ______________________________________________________

(Please Print)

Home Address: ______________________________________Phone: _________________

(Please Print)

************************************************************************

This space reserved for System Administrator

Submitted to SIS:___________________________ (initials)