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REGISTRATION FORM INSTRUCTIONS
STUDENT INFORMATION: (Please fill in all blanks on the registration form.)
Preferred Name:
Is the name the student prefers to be address by
Special Education and Individual Education Plan:
Check Y/N if the student received Special Education Services and has an Individual Education Plan.
Mailing Address:
(If different) might be a post office box or another address where parents/guardians prefer mailing to be sent.
Student Lives With:
May be Parents, Father, Mother, Brother, Sister, etc...
PARENT/GUARDIAN INFORMATION: (Please fill in all blanks on the registration form.)
Contact 1: May be either parent or guardian.
Title: May be Mr., Mrs., Ms., Dr., etc.
Residence Address: Is filled in only if is different from the student address
Contact 2: Is the other parent or guardian, if applicable
EMERGENCY CONTACTS:
Contacts 1 & 2 should be local contacts in case of emergency or early dismissal from school
HOME LANGUAGE SURVEY:
This information is used to determine eligibility for English as a Second Language (ESL) services
ETHNIC BACKGROUND:
Required by Federal Law.
TRANSCRIPT RELEASE FORM:
Completion is required in order to receive the necessary records from your child’s previous school.
**AFTER ALL INFORMATION IS FILLED IN, PLEASE RETURN THE REGISTRATION FORM FOR
REVIEW BY THE REGISTRATION CLERK. **
THE FOLLOWING DOCUMENTATION IS REQUIRED FOR REGISTRATION.
1. Official Birth Certificate
2. Up to date Immunization Records
3. Proof of Residency ~ 2 forms are required. Please see following page for acceptable documents.
All documents must be current
4. Court Order if Guardian, or any court documentation pertaining to the child.
SCHOOL ADMISSIONS
Any child qualified for admission to the Bristol Warren Regional School District may at any time be admitted to school by
completing the established admissions and residency protocols.
In order to establish residency for the purpose of enrolling students in the Bristol Warren Regional School
District, you must provide two current sources of residency verification; one primary source from list A and one
secondary source from list B.
You may use list C only if it is determined that you are unable to provide the items listed in both A. and B.
A. Primary:
Mortgage Statement or
Real Estate Tax Bill or
Formal Lease (signed by both parties) or
Notarized Letter from Landlord including current date, name of landlord, name of tenant/s and
address
(must be accompanied by RE Tax Bill or Mortgage Statement in Landlord’s name).
B. Secondary: Household Utility Bill
Gas or
Water or
Electric or
Oil
C. Affidavit of Residency: (only if unable to use options A and B) must provide all three documents
a. Notarized Affidavit of Residency by Parent – (cannot be notarized by an employee of the Bristol
Warren Regional School District)
b. Notarized Affidavit of Residency by Resident – (cannot be notarized by an employee of the Bristol
Warren Regional School District)
c. One item from either A or B in resident’s name
The school department will conduct registration of students who plan to enter Bristol Warren Regional School District for
the first time during the spring preceding the school year of admission.
ADOPTED: January 24, 1994
Revised: July 16, 2007
December 9, 2013
LEGAL REF.: 16-38-2
16-64-1 http://webserver.rilin.state.ri.us/Statutes/title16/16-38/16-38-2.htm http://webserver.rilin.state.ri.us/Statutes/title16/16-64/16-64-1.htm
CROSS REF.: JEB, Entrance Age
JECA/JECB, Admission of Resident/Nonresident Students JHCB, Inoculation of Students
School Year:__________________ Date of Application: ___________________________
BRISTOL WARREN REGIONAL SCHOOLS – REGISTRATION FORM
STUDENT INFORMATION:
Last Name First Name Middle Initial Preferred Name
Yes No Yes No
Grade Gender Date of Birth Special Education Individual Education Plan
Date of entry into USA (if not born in USA) _______________
STUDENT RESIDENCE:
(401) -
Number / Street Apt. # City State Zip Home Phone
Student lives with: _________________________________________ Student Mailing Address (if different) ____________________________________________
Mother’s Email Address: ________________________________________ Father’s Email Address: ______________________________________________
Other children in family _______age _______age _______age _______age
PARENT / GUARDIAN INFORMATION:
Contact 1:
Relationship to student Title Last Name First Name Middle Initial
(401) -
Number / Street Apt. # City State Zip Phone cell / home (circle one)
(401) -
Employer Employer Address City State Zip Work Phone
Contact 2:
Relationship to student Title Last Name First Name Middle Initial
(401) -
Number / Street Apt. # City State Zip Phone cell / home (circle one)
(401) -
Employer Employer Address City State Zip Phone
Please provide two local contacts if we are unable to reach parent or guardian or in case of an early dismissal:
Emergency Contact 1:
Relationship to student Title Last Name First Name Middle Initial
(401) -
Number / Street Apt. # City State Zip Phone cell/ home (circle one)
Emergency Contact 2:
Relationship to student Title Last Name First Name Middle Initial
(401) -
Number / Street Apt. # City State Zip Phone cell / home (circle one)
(401) -
Student Doctor’s Name Doctor’s Address City State Zip Phone
Has your child ever attended Bristol Warren School? Yes No If yes where ___________________Years_____________________
School transferring from: _______________________________________________________________
RACE ETHNICITY DATA COLLECTION
In accordance with new race and ethnicity guidelines from the U.S. Department of Education, please respond to BOTH of the following questions:
1. Is this child or student (or Are you) Hispanic / Latino? (Choose only one of the following):
No, Not Hispanic / Latino
Yes, Hispanic / Latino (A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or
origin, regardless of race.
The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking
one or more boxes to indicate what you consider your child or student’s (or your) race to be.
2. What is the child or student’s (or your) race? (Choose one or more from below)
American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America (including
Central America,), and who maintains tribal affiliation
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, the Philippine Island, Thailand, and Vietnam.)
Black or African American (A person having origins in any of the black racial groups or 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.)
Signature of Adult Relationship to Student Date
Subscribed and Sworn to pursuant to Rhode Island General Laws this to Rhode Island General Laws this ________________________day of ________________________
____________________________________________________________
Notary Public
Print Name of Notary ____________________________________________________________
Address of Notary ____________________________________________________________
***************************************************************************************************************************
OFFICE USE ONLY ( NO REGISTRATION IF THIS FORM IS NOT COMPLETED)
Y / N Y / N Y / N / / Y / N
Birth Certificate Immunization Verified Residency Confirmed Residency Document Area Confirmed
/ / / / / / Y / N
Start Date ID# Siblings – School Transcript Requested Home School
/ / /
School No. Homeroom District
The aforementioned student must be a legal resident of Bristol Warren. Proof of residency may include lease agreement, tax, bill, utility bill or any
combination as required by the School Department.
The undersigned herby certifies that this student is legally residing permanently with me at the aforementioned address and is not merely in residence only to attend school in Bristol Warren. Should student’s address change at any time, I will immediately notify the Bristol Warren Public Schools.
I understand that should student fraudulently register for school or become a non-resident and remain in school, I will be personally responsible for the payment
of tuition at the prevailing rate. Pursuant to the Rhode Island General Laws section 11-18-1 (false documents, and Section 11-33-1 (perjury), I certify that the provided information is true and
may be relied upon in enrollment in the Bristol Warren Public Schools at public expense.
11-18-1 GIVING FALSE DOCUMENT TO AGENT, EMPLOYEE, OR PUBLIC OFFICIAL .. No person shall knowingly give to any agent, employee, or servant in public or private employ, or public official any receipt, account, or other document in respect of which the principal, master, or employer
particular, and which, to his knowledge, is intended to mislead the principal, master, employer, or state, city, or town of which he is an official. Any
person who violates any of the provisions of the section shall be deemed guilty of a misdemeanor, and shall, on conviction thereof, be imprisoned, with or without bard labor, for a term not exceeding one (1) year, or be fined not exceeding one thousand dollars ($1000).
173 PERJURY AND FALSE SWEARING 11-33-1. PERJURY. Every person of whom an oath or affirmation is or shall be required by law, who shall willfully
swear or affirm falsely in regard to any matter or thing respecting which such oath or affirmation is or shall be required, shall be deemed guilty of perjury.
(Seal)
Bristol Warren Regional School District
151 State Street, Bristol, RI 02809-2205
LANGUAGE SURVEY FORM
The cultural composition of our community is one of our major assets. Language is a major means of cultural expressions. Accordingly, we are attempting
to identify the cultural resources we have in our community. This questionnaire will help us in determining the home language of all students and also
assist us in providing each student with the most appropriate educational program.
__________________________________ _____________________________ _______ ________
LAST NAME FIRST NAME M.I. GRADE
1. What Languages are spoken in your home? English ________ Other ________
2. Which Language did your child learn when he/she first began to talk? English ________ Other ________
3. What Language do you use most frequently when speaking to your child? English ________ Other ________
4. What Language does your child use most frequently when speaking to you? English ________ Other ________
5. What Language does you child use most frequently when speaking to others? English ________ Other ________
6. If your child is cared for by another person on a regular basis, what language English ________ Other ________
is most frequently used?
7. In what Language do you prefer communications be sent home? English ________ Other ________
STUDENT INFORMATION
In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you
complete the following information regarding you child. Your cooperation is appreciated.
Student Social Security Number: _________________________ (Check one): Male______ Female ______
Check one of the following Race / Ethnic Groups:
____Hispanic ____Black ____White ____American Indian / Alaskan Native ____Asian / Pacific Islander
Date:_________________________ Signature of Parent/Guardian _____________________________________
The Bristol Warren Regional School District does not discriminate on the basis of age, sex, race, religion, national origin, color, disability or
sexual orientation in accordance with applicable laws and regulations.
Rev. 2-2003
Authorization for Release of Information to
Bristol Warren Regional School District
I herby authorize the _________________________________________________________
(School Name & Address)
to release the following information from the record of: _______________________________ (Name of Student)
to the Bristol Warren Regional School District.
Date of Birth: _____/_____/_____ Last Grade Attended: __________
Signature of Parent / Guardian Date
REQUESTED INFORMATION:
Cumulative Folder _________
Health Record _________
Attendance Record _________
Copy of Latest Report Card _________
Educational Testing Results _________
Individual Educational Plan (IEP) _________
Remedial/Chapter 1 Services _________
Other (Please specify) _________
Please send information to:
Kickemuit Middle School
Attn: Bethanie Maduro-Antonio
525 Child Street
Warren, RI 02885
**Parental permission is no longer required when records are requested by authorized personnel.**
(Family Educational Right and Privacy Act, Final Rule on Educational Records. Federal Register, June 17, 1976, Vol. 41, No. 118,
page 24673).
Bristol Warren Regional School District 151 State Street, Bristol, RI 02809 Tel. 401-253-4000 Fax. 401-253-0829
Leslie J. Anderson, M.Ed., Director
Office of Pupil Personnel Services Release of Information
Student Name: ______________________________________ Date of Birth:_________________ Student is (please check one) ____entering ____leaving ____currently enrolled at: ____________________
I hereby authorize Bristol Warren Regional School District Pupil Personnel Office to:
Obtain From: Release To:
Name: _______________________________ Name: _______________________________
Address: _____________________________ Address: _____________________________
_____________________________ _____________________________
Tel: _________________________________ Tel: _________________________________
Fax: _________________________________ Fax: _________________________________
Give/Receive by: ______Mail ______Fax ______in person/telephone ______any/all
Psychological____ Speech/Language____ Occupational Therapy____
Social ____ Medical ____ Physical Therapy ____
Psychiatric ____ Educational ____ I.E.P. ____
Vocational ____ FBA ____ Adapted Behavior ____
Other:_______________________________________________________________________
For the purpose of: _____Educational Planning or Other:___________________________
Any information received shall not be further relayed to any other source without written consent.* I hereby release the Bristol Warren Regional School District and its duly authorized agents from all legal responsibility for the release of information indicated and authorized herein.
Signed: _________________________________ Date: _____________________
Print Name: __________________________________________________________
Relationship to student: _____________________ Contact Tel: ________________
*Consent means that the parent/guardian has been fully informed of all information relevant to the activity for which consent is sought, his or her native language, or other mode of communication. The parent understands and agrees in writing to the carrying out of the activity for which his or her consent is sought, and the consent describes that activity and lists the records (of any that will be released and to whom,) and the parent understands that the grant of consent is voluntary on the part of the parent and may be revoked at any time.
Kickemuit Middle School
525 Child Street
Warren, RI 02885
Tel. 401-245-2010
Fax 254-5960
Medication Consent for administration of:
Acetaminophen (generic Tylenol)
Ibuprofen (generic Advil/Motrin)
Antacid: Tums, Maalox or Mylanta
● In order for the above medication to be given to students for minor complaints at Kickemuit Middle
School, this form must be signed by parent or guardian.
● Should the school nurse consider the number of requests for medication to be excessive, the parent or
guardian will be contacted and will recommend medical evaluation for complaints.
● This permission will remain in effect for their tenure at Kickemuit Middle School or until it is withdrawn
in writing or the student leaves the school system.
● Administration of any other medication at school requires a written physician's order and parent signature.
● Medication Authorizations Forms can be obtained on the district website on the Parents page,
http://www.bwrsd.org/pages/Bristol_Warren_Regional_School/Parents
● Look for “Information and Forms” on the left hand side of page. Scroll down and you will see link
entitled “Physician and Parent Medication Consent Form”.
http://www.bwrsd.org/files/_tVK1c_/079533323f02daef3745a49013852ec4/Physician_and_Parent_Medic
ation_Consent_Form.pdf
I grant permission for the administration of acetaminophen, ibuprofen and/or antacid to:
Student’s Name: ________________________________________ while a student at Kickemuit Middle School.
Parent/guardian Signature: __________________________________ Date: _________________
Home Telephone: __________________________________________________
Parent/Guardian Cell phone: _________________________________________
Parent/Guardian Work telephone: _____________________________________
*Note: Please be sure the school has current home, cell, work & emergency contact information for this student.
Any changes should be placed in writing, signed and sent into the main office. Thank you
Mrs. Erin Welchman RN
School Nurse
KICKEMUIT MIDDLE SCHOOL
Dear Parent/Guardian: Please assist me in updating your child’s school health record. Please complete this form and return it to school. 1. Student’s Name
2. Physician/Health Center Name
Telephone # Date of last physical examination
3. Does your child have a health problem? Diabetes Asthma Seizures Heart Skin
Menstrual issues Migraines/frequent headaches Stomach Bowel/bladder
Vision glasses/contacts Hearing Emotional/mental health issues
Recent injuries/surgery 4. Does your child take any medication on a daily basis? Reason
Name of medication Amount
Time of day given
Are there any medications your child needs to use on an ‘”as needed basis”?
Name of medication Amount
Reason for medication
5. Does your child have any allergies? Please list them
Type Reaction Treatment
6. Is there anything more about your child’s health that you think is important for me to know?
Please call me if you have any health concerns about your child you would like to discuss, at 245-2010, Ext. 2009. Be sure your emergency contact phone numbers are correct. Thank you, Mrs. Erin Welchman, RN
Parent’s Signature Date: ________
Student Name: Last First Middle Date of Birth Sex
Address: Street Apt # City State Zip Code Home Phone
KICKEMUIT MIDDLE SCHOOL Health Care Provider Name and Address
525 CHILD STREET
WARREN, RI 02885 PHONE:
STATE OF RHODE ISLAND SCHOOL PHYSICAL FORM
This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4)
PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript). IMMUNIZATIONS Please enter dates in MM/DD/YYYY format
Hepatitis B
Diphtheria-Tetanus-Pertussis DTP/DTaP
Check if DT
Check if DT
Check if DT
Check if DT
Check if DT
Pneumococcal Conjugate PCV
Polio Haemophilus Influenzae Type B
Hib
Measles-Mumps-Rubella MMR
Varicella
Student has history of varicella disease Tetanus-Diphtheria-Pertussis
TdaP/Td Check if Td Check if Td Check if Td
Rotavirus
Hepatitis A
Meningococcal
HPV
Immunization Exemption: Medical Religious
Hep B DTaP PCV Polio Hib MMR Varicella Td/Tdap Rotavirus Hep A Mening HPV
PHYSICAL EXAMINATION
Date of PE / / Height Weight BP
Please note any health problem, chronic health condition or disability that may affect behavior or health at school:
ASTHMA: No Yes DIABETES: No Yes OTHER:
Significant Systems Findings:
ALLERGIES: No Yes (Please explain) EPINEPHRINE AUTO-INJECTOR REQUIRED: No Yes
Treatment Plan:
MEDICATION (REQUIRED AT SCHOOL): No Yes (Please list)
Other medication(s) that may affect behavior or health at school:
RESTRICTIONS: Can participate in physical education: Fully With limitation
Can participate in sports: Fully With limitation
LEAD SCREENING (Required for children < 6 years of age only) Student is in compliance with lead screening requirements:
Yes No
SCOLIOSIS SCREENING
Yes No
VISION SCREENING (Children entering Kindergarten) Passed screening Screened and referred for comprehensive exam
Referred for comprehensive exam, but not screened
Screening Date: Comprehensive Exam Date: TUBERCULOSIS (If required by school district) Date of TB test:
HEALTH CARE PROVIDER SIGNATURE: DATE:
PRINT NAME: _________________________________________________________________
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