Student Registration Form - Johnston Public Schools

File Name: JPS Registration Form r6-2020 (EN)

Johnston Public Schools

Student Registration Form

REGISTRATION DATE: / / TIME : : AM/PM DATE: / / GRADE:

THIS SECTION FOR OFFICE USE ONLY

IDENTIFICATIONIDENTIFICATION

Birth Certificate (Original) Passport DCYF Intrastate ID Card (also serves as proof of residency)

IMMUNIZATIONSIMMUNIZATIONS

Checked by:

Checked on: / /

[ ] Complete

[ ] DCYF

PROOFPROOF OFOF RESIDENCYRESIDENCY

[ ] Purchase and sales agreement

[ ] Property tax bill (in name)

[ ] Current utility bill : gas /electric /landline telephone bill)

[ ] Residency Affidavit

[ ] Bank Closing Settlement Sheet

[ ] DCYF Intrastate ID Card)

PLACEMENTPLACEMENT

Special Ed placement [ ] IEP [ ] 504

Out-of-district [ ] ELL (check if required)

Confirmed with

SCHOOLSCHOOL

[ ] Graniteville (PK) AM/PM 16110

[ ] Early Childhood Center (K) 16114

[ ] Sarah Dyer Barnes Elementary (K-5) 16108

[ ] Brown Avenue Elementary (1-5) 16106

[ ] Winsor Hill Elementary (1-5) 16109

[ ] Thornton Elementary (1-5) 16103

[ ] Nicholas A Ferri Middle School (6-8) 16111

[ ] Johnston High School (9-12) 16112

[ ] Other ______________________________

Student Details

Student Name: _______________________________________________________________________________ Grade: (Legal Last Name/s) (First Name) (Middle Name)

Home Address: _________________________________________________________________________________________________ (House Number) (Street Name) (Apt./Unit #) (City) (State) (Zip)

Gender: □ Female □ male Date of Birth: Country of Birth: _____________________

STEP 1: Student Information LASID # Local Student ID

PLEASE PRINT and COMPLETE EACH SECTION

Student History

Indicate date first enrolled in ANY U.S. school. ___________________________ (Month / Day /Year)

School last attended: (School Name) (Location) (Phone number)

Has your child ever been enrolled in the Johnston Public Schools? Yes No

Student Ethnicity and Race

New Federal standards require that school districts collect and report information regarding race and ethnicity .

What is your child’s race?

American Indian/Alaskan Native Black/African American Native Hawaiian/Other Pacific Islander White Asian

If your child is Southeast Asian, please indicate their country of origin or ethnic group. Brunei Burma (Myanmar)

Cambodia Philippines Hmong Indonesia Laos Malaysia Thailand Timor-Leste Singapore Vietnam

Is your child Hispanic or Latino? Yes No

I certify that the information I have provided in this document is accurate, and that the child named above will be per-

manently residing at the indicated address. It is my responsibility to notify the school of any change of information.

Parent/Legal Guardian Signature: Date:

Specialized Services Section

Does your child presently have an Individualized Education Plan (IEP)? Yes No

Are you providing a copy of your child’s IEP? Yes No

Has your child had a screening test with Child Outreach? Yes No

Does your child have a Section 504 Plan? Yes No

Does your child presently receive any English Language Learner (ELL) instruction? Yes No

Does your child receive any other services not already mentioned? If yes, please explain: Yes No

HOME LANGUAGE SURVEY

Signature acquired from person

[ ] Giving HLS

[ ] Reviewing & Interviewing

[ ] Giving Language Assessment

[ ] Reporting Scores


Custody Arrangement (CIRCLE ONE): SOLESOLE DUALDUAL N/AN/A If living with foster parents, agency name:

1) Parent/Guardian FatherFather MotherMother Has legal custody Yes No Name

Address: Cell Phone: (If different from student)

Email Address: Work Phone:

Language spoken at home: Home Phone:

2) Parent/Guardian FatherFather MotherMother Has legal custody Yes No Name

Address: Cell Phone: (If different from student)

Email Address: Work Phone:

Language spoken at home: Home Phone:

Do you have other children attending Johnston Public Schools? Yes No If yes, please list name and grade below.

Emergency Contacts and Release Procedures

In the event of a major illness or injury, 9-1-1 will be called first. If you are unavailable, we will contact the individuals below in the order listed in the event of an illness or emergency involving your child. The people listed should be available during school hours. Your child may also be released to these individuals under other circumstances at your request or the school’s request. Suitable identification (e.g., driver’s license) will be necessary before the child is released. These are the only people authorized to pick up your child from school. Please complete this section as accurately as possible.

I, authorize the school to release my child to the individuals named below: PARENT / GUARDIAN NAME (PLEASE PRINT)

Name Relationship Daytime Phone (Please indicate home, work or cell)

1.) (H) (W) (C)

2.) (H) (W) (C)

3.) (H) (W) (C)

Permission to photograph/videotape your child

We are proud of our students and the events that take place at our schools. Occasionally throughout the year, we invite the press to report on our events. If we have permission to photograph your child, you DO NOT need to do anything. CHECK THE BOX BELOW IF YOU DO NOT GIVE PERMISSION FOR YOUR CHILD TO BE PHOTOGRAPHED, VIDEO-

TAPED AND/OR ON THE DISTRICT WEB SITE.

I do not consent for my child to be photographed or videotaped at school events or published in media or on school websites.

Parent/ Guardian Signature: Date:

Page 2 of 9 Student Registration Form—Continued

Student Name: Date of Birth: Grade:


STEP 2: Family Information LASID # Local Student ID

PLEASE PRINT and COMPLETE EACH SECTION



Health History Form


STUDENT NAME: (PLEASE PRINT) □ male □ Female DATE OF BIRTH:

Last Name First Name MI

/ / Month Day Year

Home Address:

Street Name City State Zip

Parent/Guardian Information: (PLEASE PRINT)

Name

Home Number

Work Number

Cell Number

Street Address (If different from Student) City State Zip

Name

Home Number

Work Number

Cell Number


Health Care Provider: (PLEASE PRINT)

Name

Telephone Number


MEDICAL HISTORY (Please check one response for each of the following diseases or conditions)



Student Name: Date of Birth: Grade:


Health History Information (Continued)

MEDICATIONS

Is the student currently taking any medications? Yes No

If yes, please provide the name of the medication(s) below:

1. Dosage: Number of times daily?

Prescribing physician: Reason for the medication:





IN THE SPACE BELOW, PLEASE PROVIDE ANY ADDITIONAL HEALTH INFORMATION, WHICH YOU FEEL WOULD BE HELPFUL TO THE SCHOOL NURSE-TEACHER:

What school did your child last attend?

City/Town State Telephone Number

I UNDERSTAND THIS INFORMATION MAY BE SHARED AND DISCUSSED WITH SCHOOL PERSONNEL IF NECESSARY. I GIVE PERMISSION TO APPROPRIATE SCHOOL PERSONNEL TO COMMUNICATE AND EXCHANGE INFORMATION WITH THE STUDENT’S PHYSICIAN, IF NECESSARY.

SIGNATURE PARENT/GUARDIAN DATE

Does your child have asthma? Yes No If Yes, list the triggers:

Medications prescribed: Medication required during school day? Yes No

Time of year asthmatic episodes most often occur:

Does your child have diabetes? Yes No If Yes, age of diagnosis: Type 1 or Type 2

Insulin dependent: Yes No If Yes, pump or injection:

Does your child have any vision defects? Yes No If Yes, please specify:

your child wear contacts? Yes No Glasses? Yes No Is it necessary for your child to sit near board? Yes No

Does your child have any hearing defects? Yes No If Yes, please specify:

your child wear hearing aids? Yes No Use an FM device? Yes No

Is it necessary for your child to sit near front of room? Yes No If Yes, please circle which side of the room they would prefer? Left Right

Telephone (401)222-4600 Fax (401)222-6178 TTY (800)745-5555 Voice (800)745-6575 Website: www.ride.ri.gov

The R.I. Board of Education does not discriminate on the basis of age, sex, sexual orientation, gender identity/expression, race, color, religion, national origin, or disability.

File Name: EN HomeLangSurvey-JPS-new-final-7-01-2020 Page 5 of 9

Home Language Survey (HLS) To be completed by Parent or Guardian

Dear Parent or Guardian,

The information requested on this

form is necessary for the most

appropriate school placement of

your child, and will not be used for

any other purposes1.

Thank you for your collaboration.

Student Name:

First Middle Last

Date of Birth: Place of Birth2:

_______________________________ ________________________________ Month Day Year

Parent or Guardian Relationship to Student:

Mother Father Other _______________________________

Home Language Code:

Language Background (Please check all that apply)

1. What is the primary language used in the home, regardless of the language spoken by the student?

English Other _________________________________________ Specify

2. What is the language most often spoken by the student?


3. What is the language that the student first acquired?


4. What language(s) does your child understand?


5. What language(s) does your child speak? English Other ____________________________ Specify

Does not speak

6. What language(s) does your child read? English Other ____________________________ Specify

Does not read

7. What language(s) does your child write? English Other ____________________________ Specify

Does not write

1 Required by Rhode Island Law (R.I.G.L. 16-54-2) and the Equal Opportunity Education Act (20 U.S.C. 1703(f)) 2 Families are not required to provide the place of birth, but providing the information can help LEAs to better prepare to be culturally responsive. Last Updated 4/30/2020

http://www.ride.ri.gov/

Telephone (401)222-4600 Fax (401)222-6178 TTY (800)745-5555 Voice (800)745-6575 Website: www.ride.ri.gov

The R.I. Board of Education does not discriminate on the basis of age, sex, sexual orientation, gender identity/expression, race, color, religion, national origin, or disability.

Page 6 of 9

Family Interview – Educational History 1. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write

in English or any other language? If yes, please describe them.

Yes No

Not Sure *If yes, please explain: ______________________________________________________

2a. Has your child ever been referred for a special education evaluation in the past? No Yes*

* If referred for an evaluation, has your child been identified? No Yes*

* If referred for an evaluation, and identified has your child ever received any special education services in the past?

No Yes – Type of services received: _______________________________________________________________________

2b. Age at which services received (Please check all the apply)

Birth to 3 years (Early Intervention)3 to 5 years (Special Education) 6 years or older (Special Education)

2c. Does your child have an Individualized Education Program (IEP), or a 504 plan? No Yes

3. In which language do you prefer to receive oral communications from the school or district? English Other _______________________________________

Specify

4. In which language do you prefer to receive written communications from the school or district? English Other _______________________________________

Specify

5. Indicate date first enrolled in any US. School ________________________________________________________________ (mm/dd/yyyy)

Is there anything else that you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________ __________________________________________

Signature of Parent or Guardian Date: Month Day Year

_______________________________________

Print Parent/Guardian Name OFFICIAL ENTRY ONLY – NAME/POSITION OF PERSONNEL ADMINISTERING HLS

Name: _____________________________________ Position: _____________________________________________

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS: _________________________________________________ NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLS AND CONDUCTING INDIVIDUAL INTERVIEW

Name: _____________________________________ Position: _____________________________________________

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS: _________________________________________________

Oral Interview Necessary Yes No Date of Individual Interview: ___________________________________ Month Day Year

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING THE LANGUAGE SCREENING ASSESSMENT

Name: _____________________________________ Position: _____________________________________________

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS: _________________________________________________ NAME/POSITION OF QUALIFIED PERSONNEL REPORTING THE LANGUAGE SCREENING SCORES

Name: _____________________________________ Position: _____________________________________________

Date of Screener: ________________ Month Day Year

Name of Language Screening Assessment: __________________________ Score Achieved: ___________________

Proficiency Level Achieved: Entering 1 /Beginning 2 / Developing 3 / Expanding 4 / Bridging 5 / Reaching 6

FOR STUDENTS WITH AN IEP OR 504 PLAN, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED: ________________________________________

_____________________________________________________________________________________________________________________

http://www.ride.ri.gov/

PAGE 7 OF 9

JOHNSTON PUBLIC SCHOOLS 10 MEMORIAL AVENUE JOHNSTON,

RHODE ISLAND 02919-3222

File Name: ResidencyAffidavit_2020-2021

AFFIDAVIT AFFIRMING RESIDENCY

PART A – TO BE COMPLETED BY PARENT/GUARDIAN

(1) I ________________________ certify that I reside at _______________________________, (Name of parent/guardian) (Street address)

Which is located in Johnston, Rhode Island, and I further certify that the following child(ren) reside at this

address with me:

Name Date of Birth Relationship

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

(2) PLEASE CHECK ONE:

I own and reside at the residence located at the address listed above.

I rent or otherwise reside at all or a portion of the residence located at the address listed

above, but I am not the owner. (3) I have enclosed copies of the following documents as proof of residence for the child(ren) listed above:

(Please provide at least three (3) documents from the following list. Monthly bills must be

dated within the previous thirty (30) days)

Copy of deed and most recent mortgage payment Bank Statement Copy of lease agreement and proof of most recent rental payment Current Payroll Stub Section 8 Agreement Current Vehicle Registration Recent Insurance bill/policy Credit Card Statement W-2 Tax return for previous year Electric, cable, gas or water bill Current property or motor vehicle tax bill Current proof of SNAP/SSI Benefits

ACKNOWLEDGEMENT

I certify that the above information is true and correct. I understand that this information will be verified by

the Registrar, and if found to be fraudulent, I understand that the falsification of any information on this

form may result in me being liable to the Town of Johnston for the reimbursement of any expenses

incurred by the Town in educating the listed child(ren) and/or being subject to criminal prosecution

resulting from any fraud or negligent misrepresentation contained on this form. I acknowledge that as

Parent/Guardian, I must immediately notify the Johnston Public Schools of any change in residency and

provide proof in support of any new residency.

______________________________________ ________________________________

(Signature of Parent/Guardian) (Date)

Subscribed and sworn to before me on this __________day of _____________, 20__.

______________________________________ (Notary Public) My commission expires: _________________

PAGE 8 OF 9

JOHNSTON PUBLIC SCHOOLS 10 MEMORIAL AVENUE JOHNSTON,

RHODE ISLAND 02919-3222

File Name: ResidencyAffidavit_2020-2021

AFFIDAVIT AFFIRMING RESIDENCY

PART B – TO BE COMPLETED BY HOMEOWNER (IF DIFFERENT FROM PARENT/GUARDIAN)

(1) I __________________________________ certify that I am the owner of the property located at

________________________________________________, which is located in Johnston,

Rhode Island, and I further certify that ________________________________ resides full-time

at this property with the following child(ren):

____________________________________________________________.


I own the property at the address listed above and I reside there.

I own the property at the address listed above, but I reside elsewhere, I reside at the following

address:

____________________________________________________________________ .


I have a current rental agreement with the parent or guardian / tenant named above for the

house or apartment located at the address listed above.

The parent or guardian / tenant and the child(ren) listed above reside with me at the above–

stated address. Please state the reason that the parent or guardian / tenant and the child(ren)

reside at this address with you:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

ACKNOWLEDGEMENT

I certify that the above information is true and correct. I understand that the Registrar for the Johnston Public Schools will verify by homeownership status with the Registry of Deeds and the Tax Assessor for the Town of Johnston, and if the information I have given is found to be fraudulent, I understand that the falsification of any information on this form may result in me being liable to the Town of Johnston for the reimbursement of any expenses incurred by the Town in educating the listed child(ren), and/or being subject to criminal prosecution resulting from any fraud or negligent misrepresentation contained on this form.

______________________________________ ________________________________

(Signature of Homeowner) (Date)

Subscribed and sworn to before me on this __________day of _____________, 20____.

______________________________________ (Notary Public) My commission expires: _________________

Revised 7-10

STATE OF RHODE ISLAND

School Name & Address:

Health Care Provider Name and Address: Phone:

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) Student Name: Last First Middle Date of Birth

Sex

Address: Street Apt # City State Zip Code Home Phone

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

Immuni

zation 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

TUBERCULOSIS (If required by school district) Date of TB test:

Screening Date: Comprehensive Exam Date:

HEALTH CARE PROVIDER SIGNATURE: ________________________________________________________________ DATE: _________________________________

PRINT NAME: ________________________________________________________________

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Student Registration Form - Johnston Public Schools