Welcome to the Newark Central School District

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Welcome to the

Newark Central School District

School reet Newark

Perkins Ehang,ant.n,439 West Grades U

Elementary Registration Packet

TO BE COMPLETED BY SCHOOL PERSONNEL: Student: ____________________________ Transfer from: _______________________ Notes to Staff: _______________________

____ Perkins Elementary School 439 West Maple Avenue, Newark

Grades UPK, K, 1, 2

____ Lincoln Elementary School 1014 North Main Street Newark

Grades UPK, K, 1, 2

____ Kelley Intermediate School 316 West Miller Street, Newark

Grades 3, 4, 5

** IMPORTANT**

THE FOLLOWING DOCUMENTS NOTED BELOW MUST BE COLLECTED

BEFORE YOUR CHILD CAN ENTER SCHOOL

Proof of Residency. Acceptable forms are: *Mortgage agreement or purchase offer. *Utility bill with billing address. *Driver’s license with current address of custodial parent/guardian. *Rental agreement signed by rentee and landlord and dated.

Proof of Age Health Records/Immunization History Custody Papers and/or family Court papers **

(These documents must be dated, current and signed by a Judge

Order of Protection ** (These documents must be dated, current and signed by a Judge

** Provide copies of these documents only if you have them filed through a court.

ANY HANDWRITTEN LETTER YOU ARE PROVIDING TO US (IE: RENTAL

AGREEMENT, SIGNING OVER TEMPORARY GUARDIANSHIP OF A CHILD,

ETC.) NEEDS TO BE NOTARIZED. THANK YOU!!

NEWARK CENTRAL SCHOOL DISTRICT NEWARK CENTRAL SCHOOL DISTRICT

100 EAST MILLER STREET

NEWARK, NEW YORK 14513

(315) 332-3230 FAX (315) 332-3517

Date: ___________________________

NEWARK CENTRAL SCHOOL DISTRICT REGISTRATION FORMAUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request that Newark Central School receive a transcript of the health/immunizations and scholastic records for my son/daughter from:

NAME OF PREVIOUS SCHOOL: ______________________________________________________________ ADDRESS: ______________________________________________________________ ______________________________________________________________ PHONE: (______)___________________ FAX: (______)_______________________

STUDENT NAME: ______________________________ GRADE: _______ D.O.B.: ___________

SIGNATURE OF PARENT/GUARDIAN: ______________________________________________** PLEASE SIGN **

** These records should include ** Transcripts of grades (including grades in progress up to the date of withdrawal*)

*Please provide numerical equivalent if alphabetical grades are reported*Test scores, including Competency Test Scores/State Assessments Health/Immunization Information Guidance Information, Special Education, 504 Records Evaluation Reports (Psychological, Related Services, etc.) AIS Records Instructional Support Team Interventions and Notes ESL Service Records

Newark Senior High School – Grades 9 – 12 Attn: MaryBeth Springett, Building Secretary 625 Peirson Avenue, Newark, NY 14513 Tel: (315) 332-3268; Fax: (315) 332-3275

Newark Middle School – Grades 6 – 8 Attn: Kathy Sapp, Building Secretary 701 Peirson Avenue, Newark, NY 14513 Tel: (315) 332-3304; Fax: (315) 332-3584

N. R. Kelley Intermediate School – Grades 3 – 5 Attn: Brenda Bigley Vestal, Building Secretary316 West Miller Street, Newark, NY 14513 Tel: (315) 332-3326; Fax: (315) 332-3624

Perkins School – Grades K-2 Attn: Sarah Griepsma, Building Secretary 439 West Maple Avenue, Newark, NY 14513 Tel: (315) 332-3315; Fax: (315) 332-3614

Lincoln School – Grades K-2 Attn: Rebecca Briggs, Building Secretary 1014 North Main Street, Newark, NY 14513 Tel: (315) 332-3342; Fax: (315) 332-3604

MATTHEW L. COOKSuperintendent of Schools

KRISTA A. LEWIS Assistant Superintendent Curriculum & Instruction

EDWARD K. GNAU Assistant Superintendent

Business

KERRI LEVINE Director of Pupil Services

J

SIBLINGS / RELATIONSHIPS IN THE HOME

Newark Central School DistrictStudent Registration Form

**(PLEASE PRINT, EXCEPT WHERE SIGNATURE IS REQUIRED)**

Name: ________________________________________________________________________________ ___________ First Middle Last

Male Female Nickname (if applicable):______________________

Birth Date: _____/_____/_____ Place of Birth: ____________________________________________ _ __________ City State County

Home Phone: (____)____________________ _

Parent Cell Phone: (____)___________ Parent Email Address (Optional) : _________ ___ ___________

Home Address:______________________________________________________ __________________________ City State Zip

Apartment or Lot#:_______________

Mailing: ________________________________________________________________________________________ __ (if different from home address) City State Zip

Is one or more parents who is currently a member of the Armed Forces and on Active Duty: Yes No

Who does the child live with? Both parents Custodial Mother Custodial Father Legal Guardian

*PLEASE NOTE: STEPPARENT OR SIGNIFICANT OTHERS MUST BE LISTED UNDER “OTHER” ON PAGE 3 OF REGISTRATION

Are there any custodial restrictions or an order of protection? Please explain: __________________________________ _________________________________________________________________________________________________

Copy of court paperwork submitted Yes No (PLEASE PROVIDE COPY FOR STUDENT FILE)

Is your current address a temporary living arrangement? Yes No If yes, please complete Student Residency Questionnaire. If yes, living: In a shelter With others due to lack of housing In an abandoned apartment/building

Motel/Hotel In a campground In a car In a train or bus station Other ________________________

Are you temporarily housed in a shelter awaiting an OCFS permanent foster care placement? Yes No

Has this child previously attended Newark Schools? Yes No If yes, name school last attended?________________ School Year Last Attended in Newark: _______________________________ Grade: ______________

LAST NAME FIRST NAME M.I GENDER BIRTH DATE GRADE SCHOOL ATTENDING

IF CHILD IS NOT SCHOOL AGE, WRITE “N/A” AT

GRADE

Male Female

Male Female

Male Female

Male Female

Male Female

LAST NAME FIRST NAME M.I RELATIONSHIP TO STUDENT

FOR OFFICE USE ONLYStudent #: _______________________ Grade: __________________________ EC: _____________________________ Teacher:_________________________

STUDENT INFORMATION

CUSTODIAL INFORMATION

Student’s Name__________________________________ Newark Central School District

Registration Form, Page 2

Newark Central School district assumes that all custodial parents and legal guardians listed below are allowed to pick this student up from school unless parent provides school with a current, legal, valid court order indicating otherwise. I am in agreement

Signature________________________________________________ **(Required)**

Custodial Mother Custodial Father Non-Custodial Mother Non-Custodial Father Legal Guardian

Please Check One Mr. Mrs. Ms./Miss Please Check One: Jr. Sr. I II III Name: ______ __

First Middle Last

Address: ________ (if different from child’s) City State Zip

Primary Phone: ( ) Work Phone: ( _ ) __ _________

Cell Phone: ( _ ) Parent Email Address (Optional): ____ _______ _

OK FOR THIS PERSON TO PICK UP CHILD? :YES NO



First Middle Last


Primary Phone: ( ) Work Phone: ( _ ) __ ________

Cell Phone: ( _ ) Parent Email Address (Optional): ___ __




First Middle Last


Primary Phone: ( ) Work Phone: ( _ ) __ ________

Cell Phone: ( _ ) Parent Email Address (Optional): _______


PARENT/GUARDIAN INFORMATION

}

Student’s Name__________________________________ Newark Central School District Registration Form, Page 3

Please Check One Mr. Mrs. Ms./Miss Please Check One: Jr. Sr. I II III III

Name ______ ______________ First Middle Last

Relationship to Child: Grandfather Grandmother Uncle Aunt Other _____________________________(PLEASE SPECIFY)

Home Phone: (____) Work Phone: (____) _______

Cell Phone: ( _ ) Parent Email Address (Optional): __________


Please Check One Mr. Mrs. Ms./Miss Please Check One: Jr. Sr. I II III

Name ______ ___ First Middle Last


Home Phone: (____) Work Phone: (____) ____

Cell Phone: (____) Parent Email Address (Optional): __________



Name ______ ___ First Middle Last


Home Phone: (____) Work Phone: (____) ____

Cell Phone: (____) Parent Email Address (Optional): __________


Will your child go to daycare? Before School After School Both

Babysitter Name __

Address ______________

Home Phone (____) ____ Cell Phone (____) ___ __

EMERGENCY CONTACTS (Beyond Parent/Guardian)

DAYCARE PROVIDER

Student’s Name: ________________________________________ Newark Central School District Registration Form, Page 4

In the case of when parents are living in separate households, both parents may want to be included in any mailings the school may send with information in regards to their child. Please indicate in the spaces below those parents who are to be included in mailings.

If there are any legal restrictions (Ex.: Order of Protection, Sole Physical Custody with supervised visitation) please indicate in the Custodial Information section of this registration on Page 1.

Custodial Mother Custodial Father Legal Guardian Non-Custodial Mother Non-Custodial Father


Name: ______ First Middle Last

Address: _____

Email Address (Optional): ____________________________________________________________________________



Name: ______ ___ First Middle Last

Address: _____




Name: ______ ____ First Middle Last

Address: _____ _


MAILINGS

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*** INFORMATION SHEET *** We need to update the personal information kept on each child in the school buildings. This information is needed by the offices and the school nurses in case of emergency. Please fill in this form and return it to your child’s teacher as soon as possible.

STUDENT’S NAME: BIRTHDATE:

STREET ADDRESS:

TOWN : ZIP CODE: TELEPHONE:

** PLEASE CHECK ONE **

WALKER BUS STUDENT

BUS NUMBER : WHICH DAYS? ***(If you have special transportation needs, please call the Bus Garage at 332-3330.)***

PARENT INFORMATION

MOTHER’S NAME: TELEPHONE:

MOTHER’S ADDRESS:

MOTHER’S EMPLOYER: TELEPHONE: HOURS WORK:

FATHER’S NAME: TELEPHONE:

FATHER’S ADDRESS:

FATHER’S EMPLOYER: TELEPHONE: HOURS WORK:

BABYSITTER: NAME: WHICH DAYS?

ADDRESS: BUS NUMBER:

TELEPHONE: WALK:

Are there any other individuals living in the home? Please list names

My child may be released to the following adults (other than parents) during school hours:

Emergency names and phone numbers (please try to give 2 in case we cannot reach parents – parents will always be called first. 1. TELEPHONE: 2: TELEPHONE:

The University of the State of New York • The State Education Department • Office of Bilingual Education Albany, New York 12234

Home Language Questionnaire (HLQ)

Dear Parent or Guardian:

best possible education, we need to

determine how well he or she under-

4

these questions is greatly appreciated.

Thank You

TO BE COMPLETED BY SCHOOL PERSONNEL

DISTRICT

SCHOOL GRADE

STUDENT NAME

DATE OF BIRTH

Month: Day: Year:

STUDENT IDENTIFICATION NUMBER

COUNTRY OF BIRTH / ANCESTRY

NUMBER OF YEARS ENROLLED IN SCHOOL OUTSIDE THE U.S.

NAME/POSITION OF SCHOOL PERSONNEL COMPLETING THIS SECTION

DETERMINATION: Possible LEP

English Proficient

(✔ boxes that apply)

7. In your opinion, how well does the student understand, speak, read and write English?

Very well Only a little Not at all

Understands English ❏ ❏ ❏Speaks English ❏ ❏ ❏Reads English ❏ ❏ ❏Writes English ❏ ❏ ❏

1. What language(s) is spoken in the student’s home or residence? ❏ English ❏ Other __________________________________

specify

2. What language(s) are spoken most of the time to the student, in the home or residence? ❏ English ❏ Other __________________________________

specify

3. What language(s) does the student understand? ❏ English ❏ Other __________________________________ specify

4. What language(s) does the student speak? ❏ English ❏ Other __________________________________ specify

5. What language(s) does the student read? ❏ English ❏ Other _______________ ❏ Does Not Read specify

6. What language(s) does the student write? ❏ English ❏ Other _______________ ❏ Does Not Write specify

Please print or type clearly

❏

❏

In order to provide your child with the

stands, speaks, reads and writes

English. Your assistance in answering

______________________________________________ Signature of Parent/Guardian/Other Date HLQ (2/00) 99-337 PMMonth: Day: Year:

NEWARK CENTRAL SCHOOL DISTRICT 100 EAST MILLER STREET

NEWARK, NEW YORK 14513 (315) 332-3213 FAX (315) 332-3517

STUDENT RACIAL AND ETHNIC IDENTIFICATION

To the Parent/Guardian: The New York State Education Department and the US Education Department require us to collect

and record the ethnic identity of students in the Newark Central School District in accordance with the federal categories

and definitions. The information will be used to:

- Report information to the State and Federal Education Departments.

- Plan educational programs and make sure that they are readily available to all students.

- Analyze differences in academic performance, attendance and completion of school

We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions on the back of this page.

Put a check () in the box for the category or categories which best describe your child. The Newark Central School District

understands the sensitive nature of the information and wishes to assure you that it will be kept secure and confidential in

accordance with all State and Federal student privacy laws and regulations. If the information requested is not provided on

the form on behalf of your child, a student records officer from the school or district will be required to identify the group

to which the student appears to belong, identifies with, or is regarded in the community as belonging. Thank you for your

cooperation.

To School Staff: This form will be filed in the student's permanent record as confidential information

To the Parent/Guardian: The information which you have provided on this form is confidential. It is protected

by the Confidentiality Regulations below.

The Family Educational Rights and Privacy Act (1974) prohibits unauthorized access to student records and

unauthorized release of any student record information identifiable by either student name or student

identification number.

MATTHEW L. COOKSuperintendent of Schools

KRISTA A. LEWIS Assistant Superintendent for Instruction

EDWARD K. GNAU Assistant Superintendent Business

KERRI LEVINE Director of Pupil Services

N

CONFIDENTIALITY PROCEDURES AND REGULATIONS

Please complete the form on the reverse side of this page

NEWARK CENTRAL SCHOOL DISTRICT STUDENT RACIAL AND ETHNIC IDENTICATION

All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.

Name of School:

School District Student Identification Number: Date of Birth:

Student Name: Grade Level:

DIRECTIONS TO PARENT/GUARDIAN PLEASE ANSWER QUESTIONS (1) AND (2). PLEASE READ THEM BEFORE YOU RESPOND. (For question (1) Check () the box that best describes your child.) Check () only ONE box.

1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino or of Spanish origin means of person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless or race.

2. Select one or more races from the following five racial groups (For question (2) Check () all groups that apply to your child; check () at Least ONE box.):

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 maintain tribal affiliation or community attachment.

ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

BLACK OR AFRICAN AMERICAN: A person having origins in any of the Black racial groups of Africa.

WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

_ Signature of Parent/Guardian/Other Date

Relationship to Student (please check one box below):

Mother Father Guardian Other (Specify): __________________________

YES, Hispanic

No, Not Hispanic

See reverse for important message to Parents/Guardians and

Confidentiality Procedures and Regulations.

NEWARK CENTRAL SCHOOL DISTRICT

REQUEST FOR RELEASE OF INFORMATION

/ \

NEWARK CENTRAL SCHOOL DISTRICT



(315) 332-3230 FAX (315) 332-3517

REQUEST FOR RELEASE OF INFORMATION

Student Name: Grade:

School Transferring From:

Address:

Phone: ( ) - Fax: ( ) -

Parent Signature:

Current IEP YES NO

504 Plan YES NO

ESL (English as a Second Language) YES NO

Migrant Tutorial YES NO

Remedial Reading/Math YES NO

AIS (Academic Intervention Supports) YES NO

Other

MATTHEW L. COOK

Superintendent of Schools

KRISTA LEWIS

Assistant Superintendent Curriculum & Instruction

EDWARD K. GNAU

Assistant Superintendent Business

KERRI LEVINE

Director of Pupil Services

SPECIAL EDUCATION / REMEDIAL SERVICES

(Please Check All that Apply)

I give permission to the Newark Central School District to release/obtain health information to/from my child’s physician ___________________________________________________________________________________. This information may include immunization status, physical exam and progress notes. I also give my permission for the school nurse to share any pertinent medical information with my child’s teacher(s) on a need to know basis.Parent/Guardian Signature: _________________________________________________________ Date: ___________________

HEALTH SURVEY

Student Name: _______________________________________________________________________________ D.O.B.: _______________________ Grade: ______________________ Family Physician: _________________________________________ Phone #: _________________________

PLEASE COMPLETE THIS FORM INDICATING DETAILS OF ANY MEDICAL CONCERNS RELATING TO YOUR CHILD’S HEALTH. PLEASE BE SURE TO INCLUDE TREATMENT, MEDICATIONS AND DATES. **This information will remain in the health office and will be kept confidential. Your child’s health concerns will only be shared with appropriate staff when it impacts your child’s health and safety.**

CONDITION YES NO DETAILS

Does your child have hearing or visual difficulties? If so, type of correction.

Has your child been diagnosed with a psychological disorder? If so, please indicate medication and dose.

Has your child been diagnosed with ADD/ADHD? If so, please indicate medication and dose.

Does our child take medication on a regular basis? If so, type and amount.

Has your child been diagnosed with diabetes? If so, insulin type and amount.

Has your child been diagnosed with epilepsy? Please indicate type.

Does your child have a heart murmur or other cardiac condition?

Does our child have any kidney condition?

Does your child have any breathing problems such as asthma? If so, please indicate treatment.

Has your child had any operations? If so, please indicate type and date.

Has your child had any serious injuries such as broken bones, head injuries or stitches? If so, please describe and give dates.

Is your child allergic to bees or other insects? If so, please give treatment of care required.

Does your child have any allergies to food, medication or latex? If so, please describe and give treatment required.

Please indicate any other health concerns you have regarding your child.

New York State requires immunization records within 2 weeks of enrollment. If this information is not provided within 2 weeks of entrance, your child will be held from attending school until this information is received. Please see the following chart for the current school year, immunization requirements for school entrance.

Student Physical: Per New York State Law, a physical must be presented to the school within 30 days of entrance. Please check whether your own physical or the school physician is to perform the exam.

Own __________________________ School Physician_________________________

**Important information for Out of State Transfers re-entering New York State**Per Education Law Article 19 section 903: A health certificate shall be signed by a duly licensed physician, physician assistant, or nurse practitioner, who is: authorized by law to practice in this State, and consistent with any applicable written practice agreement; or authorized to practice in the jurisdiction in which the examination was given, provided that the commissioner has determined that such jurisdiction has standards of licensure and practice comparable to those of New York

NEWARK CENTRAL SCHOOL DISTRICT NEWARK CENTRAL SCHOOL DISTRICT



(315) 332-3230 FAX (315) 332-3517

Consent to Release Medical Information

Student Name: ________________________________________________

Student D.O.B.: ___________________________

Medicaid CIN#: ____________________ Social Security # ____________________

Parent/Guardian Name: _________________________________________________

Address: ______________________________________________________________

Home Phone: ____________________________

Cell Phone: ______________________________

Medical Provider: ______________________________________________________

Medical Practice: _______________________________________________________

Address: ______________________________________________________________

Phone: ___________________________ Fax: _______________________

I hereby authorize the above medical provider or agency to provide the necessary information for my child to receive Occupational and/or Physical Therapy with the Newark Central School District.

____________________________________ ____________________________ Parent/Guardian Signature Date

For office use only: OT___ PT___

MATTHEW L. COOKSuperintendent of

Schools KRISTA A. LEWIS

Assistant Superintendent for

Curriculum & Instruction EDWARD K. GNAU

Assistant Superintendent Business

KERRI LEVINE Director of Pupil

Services

Newark Central School District Committee on Special Education

100 East Miller Street Newark, NY 14513

315-332-3209

WRITTEN NOTIFICATION REGARDING USE OF PUBLIC BENEFITS OR INSURANCE TO PAY FOR CERTAIN SPECIAL EDUCATION AND RELATED SERVICES

INTRODUCTION: You are receiving this written notification to give you information about your rights and protections under the federal Individuals with Disabilities Education Act (IDEA), so that you can make an informed decision about whether you should give your written consent to allow your school district to use your or your child’s public benefits or insurance to pay for special education and related services that your school district is required to provide at no cost to you and your child under IDEA. Funds from a public benefits or insurance program (for example, Medicaid funds) may be used by your school district to help pay for special education and related services, but only if you choose to provide your consent, as explained below.

Before your school district can ask you to provide your consent to access your/your child’s public benefits or insurance for the first time, it must provide you with this notification of your rights and protections available to you under IDEA. This notification is intended to help you understand these rights and protections, including the type of consent your school district will ask you to provide. If you choose not to provide your consent, or later decide to withdraw your consent, your school district has a continuing responsibility to ensure that your child is provided all required special education and related services under IDEA at no charge to your or your child.

Parental Consent: Beginning on July 3, 2013, before your school district can use your or your child’s public benefits or insurance for the first time to pay for special education and related services under IDEA, it must obtain your signed and dated written consent. Your school district is only required to obtain your consent one time. This consent requirement has two parts:

1. Consent to share records about your child. Your school district is required to obtain your written consent before disclosing [sharing] personally identifiable information about your child (such as your child’s name, address, social security number, Individualized Education Program (IEP), and evaluation results from your child’s education records. In asking for your consent, the district will (1) identify the records [or information] about your child that will need to be shared (for example, about the services that may be provided to your child); (2) tell you the purpose of sharing the records (for example, billing for special education and related services); and (3) identify the agency to which your school district may disclose the information (for example, the Medicaid agency).

2. Consent to bill your public insurance program (for example, Medicaid). Your consent must include a statement specifying that you understand and agree that your school district may use your or your child’s public benefits or insurance (e.g., Medicaid) to pay for some of your child’s special education services.

If your school district has on file your consent that you provided before July 3, 2013 to release your child’s records and to use your or your child’s public benefits or insurance to pay for special education and related services, your school district is required to request a new consent from you only when there is a change in any of the following: the type of services to be provided to your child (for example, physical therapy or speech therapy), the amount of services to be provided to your child (for example, hours per week lasting for the school year), or the cost of services (that is, the amount charged to the public benefits or insurance program).

If any of these changes occur, your school district must obtain from you a new one-time consent. Before you provide your school district the new, one-time consent, your school district must provide you with this notification. Once you provide this one-time consent, you will not be required to provide your school district with any additional consent in order for it to access your/your child’s public benefits or insurance even if your child’s services change in the future. However, your school district must continue to provide you with this notification annually.

You have the right to withdraw your consent at any time. If you withdraw your consent, the school district must still provide all of your child’s IEP special education and related services at no cost to you. To withdraw your consent, you will need to submit your request in writing to your child’s school district.

NO COST PROVISIONS: The IDEA “no cost” protections regarding the use of public benefits or insurance are as follows:

1. Your school district may not require you to sign up for, or enroll in, a public benefits or insurance program in order for your child to receive a free appropriate public education.

2. Your school district may not require you to pay any out-of-pocket expenses, such as the payment of a deductible or co-pay amount for filing a claim for services that your school district is otherwise required to provide your child without charge.

3. Your school district may not use your or your child’s public benefits or insurance if using those benefits or insurance would:

Decrease your available lifetime coverage or any other insured benefit, such as a decrease in your plan’s allowable number of physical therapy sessions available to your child or a decrease in your plan’s allowable number of sessions for mental health services;

Cause you to pay for services that would otherwise be covered by your public benefits or insurance program because your child also requires those services outside of the time your child is in school;

Increase your premium or lead to the cancellation of your public benefits or insurance; or

Cause you to risk the loss of your child’s eligibility for home and community-based waivers that are based on your total health-related expenditures.

We hope this information is helpful to you in making an informed decision regarding whether to allow your school district to use your or your child’s public benefits or insurance to pay for special education and related services under IDEA. Contact information: For additional information and guidance on the requirements governing the use of public benefits or insurance to pay for special education and related services see: http://www2.ed.gov/policy/speced/reg/idea/part-b/part-b-parental-consent.html.

NEWARK CENTRAL SCHOOL DISTRICT Committee on Special Education

100 East Miller Street Newark, New York 14513

Medicaid Consent

This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's Individualized Education Plan (IEP). This consent allows the School District to bill for covered health-related services and to release information to the school district’s Medicaid Billing Agent for that purpose. I, _______________________________as the parent/guardian of

, have received a written notification from the School District that explains my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services.

I understand and agree that the School District may access Medicaid to pay for special education and related services provided to my child, and that this consent extends to any eligible services provided in prior school years.

I understand that: providing consent will not impact my child’s/my Medicaid coverage; upon request, I may review copies of records disclosed pursuant to this authorization; services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid; I have the right to withdraw consent at any time; and the School District must give me annual written notification of my rights regarding this consent.

I also give my consent for the School District to release the following records/information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared.

Records to be shared (such as records or information about services your child receives)IEP

Written Order/Referral

Evaluation Reports

Session Notes

Medication Administration Report

Special Transportation Log

Other Personally Identifiable Information

Any Other Specific Records Pertaining to the Student’s Services or Program

I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.

CHILD’S CIN OR SOCIAL SECURITY # _______________________________

Parent/Guardian Signature: ____________________________________________________

Print Name: _____________________________________ Date: ____________________

____ I HAVE RECEIVED WRITTEN NOTIFICATION REGARDING USE OF PUBLIC BENEFITS OR INSURANCE TO PAY FOR

CERTAIN SPECIAL EDUCATION AND RELATED SERVICES

LI Li

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NEWARK CENTRAL SCHOOL DISTRICT HOUSING QUESTIONNAIRE

Name of School:

Name of Student: Gender: MALE

Last, First, Middle FEMALE

Birth Date: / / Grade:

Address: Phone: The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

Where is the student presently living? (Please check one box)

In a shelter

With another family or other person because of loss of housing or a result of economic hardship

(sometimes referred to as “doubled-up”)

In a hotel / motel

In a car, park, bus, train or campsite

Other temporary living situation (Please Describe):

In Permanent Housing

Print Name of Parent, Guardian or Signature of Parent, Guardian or

Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth)

Date

If ANY box other than “In Permanent Housing” is checked, , then the student/family should be immediately referred to the MV Liaison. In such cases, proof of residency and other documents normally needed for enrollment are not required and the student is to be immediately enrolled. After the student has been enrolled, the district/school must contact the previous district/school attended to request the student's educational records, including immunization records, and the enrolling district's LEA liaison must help the student get any

other necessary documents or immunizations .

PLEASE FORWARD THIS FORM TO STACY WARREN, HOMELESS LIAISON

Revised: 7/31/18

Transportation Application 2019-2020

This application must be returned to: Newark Central School District Transportation Department

310 Wood Lane, Newark, New York 14513

SCHOOL: GRADE:

Student’s name: Last Name First Name

Parent/Guardian: Child Care Provider:

Name Name

Street Address Street Address

City State Zip Code City State Zip Code

Home Phone Phone Number

Work Phone

ALL SPACES MUST BE FILLED IN OR APPLICATION WILL BE RETURNED. Place a in the appropriate boxes

Morning Pick Up Afternoon Drop Off Home Child Care No Transport Home Child Care No Transport

Monday Monday

Tuesday Tuesday

Wednesday Wednesday

Thursday Thursday

Friday Friday

I hereby authorize the Newark Central School District to transport my child to/from the locations listed above.

Date Signature of Parent/Guardian

Documents

Welcome to the Newark Central School District