Student Registration Packet WATERLOO CENTRAL SCHOOL DISTRICT
Waterloo Central School District REGISTRATION PACKET
____________________________________
Welcome to WCS! It is our goal to make this transition as quick and
positive
as possible. Please complete the attached enrollment packet and
take a
moment to gather the following items:
• Proof of child’s age (birth certificate, passport, medical card,
certificate of baptism, or other acceptable proof of age)
• Proof of residency (lease/deed, rental contact, utility bill,
letter from landlord, letter from person you are living with,
other)
• Proof of custody or guardianship (if applicable)
• Immunization records (Most Recent)
All applications are considered incomplete until all documentation
listed has been provided.
If you have any questions or need assistance, please do not
hesitate to contact us. ~~~~~~~~
Central Registrar: Heather Elisofon Direct Line 315-539-1502 / Fax:
315-539-1504
[email protected] 109 Washington Street, Waterloo,
NY 13165
Last updated 11/22/19
Rev. 9/8/17 SCHOOL USE ONLY: Student qualifies for
M.V.______________ Student does not qualify__________
NOTE TO SCHOOLS/LEAS: Please assist students and families fill out
this form. Do not simply include this form in the registration
packet, because if the student qualifies as residing in temporary
housing, the student is not required to submit proof of residency
and other required documents that may be part of the
registration
packet.
Name of School bldg:
Female Month Day Year (preschool-12) (optional)
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 currently living? (Please check one
box.)
In a shelter
With another family or other person because of loss of housing or
as a result of economic hardship
(sometimes referred to as “doubled-up”)
In a hotel/motel
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 the student is NOT living in permanent housing, proof of
residency and other documents normally needed
for enrollment are not required and the student is to be
immediately enrolled. The district’s LEA liaison is
required to assist the student in obtaining any necessary
documents, including immunization or school records
after the student has been enrolled.
NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent
housing, please ensure that a
Designation Form is completed.
I hereby certify that the above statements are true and
accurate.
Signature: ______________________________________ Date:
_______________________
_____________________ ________________ ________________
_________________________ ______________ Student Number Grade
Counselor Teacher Advisement
_____________________ ________________ ____________
_________________ __________ __________ Bus Number a.m. Bus Number
p.m. Locker Number Locker Combination Year of Grad. Cohort
_____________________ Date of Entrance
Date of Birth: Place of Birth: City State Country
Parent/Guardian Name _______________________ Child lives with this
Parent/Guardian? Y____ N____
Address:_____________________________________ Phone (Primary)
________________________
Address:_____________________________________ Phone (Primary)
________________________
Are there custody or guardianship papers? Yes No If yes, current
papers must be attached.
Comments on custody/guardianship:
_______________________________________________________
Has the student ever been enrolled in this Waterloo Central School
district? Yes No
If yes, please list grade and year of last attendance:
______________________________________
Name of School Student is Leaving: Grade:
Location of previous school:
If yes, please explain:
______________________________________
WATERLOO CENTRAL SCHOOL DISTRICT NEW STUDENT REGISTRATION
FORM
I hereby certify that the above statements are true and
accurate.
Signature: ______________________________________ Date:
_______________________
Special Education
Has your Child ever been referred for a special education
evaluation in the past? Yes No If yes, please explain?
____________________________________________________
Does the student have an IEP? Yes No
Does the student have a 504? Yes No
Does the student receive special services in school NOT associated
with an IEP or 504? Yes No If yes, please list?
____________________________________________________ ____
Has the student ever been retained? Yes No If yes, what
grade(s)?
OTHER
Is the student a Foreign Exchange student? Yes No If yes, from what
country?
Is the student currently placed in Foster Care? Yes No If yes,
through what County?
Is the student’s parent/guardian on active military duty? Yes No If
yes, describe?
Has anyone in your family worked or looked for work at an
agricultural job or farm work within the past 3 years? Yes No If
yes, describe?
In what language would you like to receive information from the
school? (Check all that apply) English Spanish Chinese
Other________________________
Would you like an interpreter available to you for better
communication with the school? Yes No If yes, please list
language/comment?
Permission
I grant permission for this student’s photo and name to be used for
school-related publicity in such media as newspapers, newsletters,
websites, television and videos. _______________________
Parent/Guardian Signature
Please List Any Siblings:
___________________________ __________ ___________________________
__________ Name DOB Name DOB
___________________________ __________ ___________________________
__________ Name DOB Name DOB
___________________________ __________ ___________________________
__________ Name DOB Name DOB
I hereby certify that the above statements are true and
accurate.
Signature: ______________________________________ Date:
_______________________
________________ ______________________ ______
_________________________ First Last Gender Relationship to
Student
Physical Residence:
__________________________________________________________________
Employer:
____________________________________________________________________
Email:
_______________________________________________________________________
Check all that apply: OK to pick up student Lives with student
Legal Custody
Receives Mailings ok to call if student is NOT in school
----------------------------------------------------------------------------------------------------------------------------------
ADULT INFORMATION (CONTACT PRIORITY #2)
________________ ______________________ ______
_________________________ First Last Gender Relationship to
Student
Physical Residence:
__________________________________________________________________
Employer:
____________________________________________________________________
Email:
_______________________________________________________________________
Check all that apply: OK to pick up student Lives with student
Legal Custody
Receives Mailings ok to call if student is NOT in school
I hereby certify that the above statements are true and
accurate.
Signature: ______________________________________ Date:
_______________________
________________ ______________________ ______
_________________________ First Last Gender Relationship to
Student
Physical Residence:
__________________________________________________________________
Employer:
____________________________________________________________________
Email:
_______________________________________________________________________
Check all that apply: OK to pick up student Lives with student
Legal Custody
___________________________________________________________________________________
________________ ______________________ ______
_________________________ First Last Gender Relationship to
Student
Physical Residence:
__________________________________________________________________
Employer:
____________________________________________________________________
Email:
_______________________________________________________________________
Check all that apply: OK to pick up student Lives with student
Legal Custody
Receives Mailings ok to call if student is NOT in school
WATERLOO UNIVERSAL PRE K REGISTRATION (Only) STUDENTS
NAME_____________________________ Please indicate your preference:
_________ _________ __________ AM PM Either
Dear UPK Parents: There are openings for 4-year-old PreK students
that live in the Waterloo Central School District for the 2021-2022
school year. If you are interested in your child attending, please
complete this registration packet and return to the district office
at 109 Washington Street.
NOTEWORTHY/REQUIREMENTS:
• This is a half-day program with no cost to families.
• Child must live in the Waterloo Central School District.
• Child must be 4 years old on or before December 1, 2021.
• New York State requirements must be met for immunizations, dental
screenings and physicals before the student can start.
• There is NO transportation to and from this program. (DO NOT
complete the transportation sheet in in the packet)
I have read and understand the obligations of UPK and my child
meets the above requirements.
Signature
20/21 School Year ____
21/22 School Year ____
Waterloo Central School District Transportation Department
D'Allah Laffoon, Director Tracy Nobles, Secretary 1719 North Rd.,
Waterloo, New York 13165
Phone (315) 539-1515 Fax (315)539-1578
Telephone: (315)-539-1515 • Fax: (315)-539-1578
Which hand does your child use? Right____ Left____
Are there any children your child should be seperated from?
Do you feel your child has any special learning needs? Please
Explain
Is there any additional information that you would like to
share?
Take turns and share? Finish one activity before starring
another?
Please help us make appropriate educational choices for your child.
Please consider the following questions carefully and place and "X"
in the appropriate box
Cooperate with adults?
Undecided____
Sit quietly for an entire story? Frighten easily? Use
pencil,crayons, scissors, and glue correctly? Use toilet
independently? Dress unassisted? Can write name?
Talk back to adults? Have temper tantrums? Show aggressive
behavior? Demand a lot of attention?
Waterloo Central School District
Student Racial and Ethnic Identification
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: WATERLOO CENTRAL SCHOOL DISTRICT
School District Student Identification Number: Date of Birth
(Month/Day/Year):
/ /
DIRECTIONS TO PARENT/GUARDIAN
Please answer questions (1) and (2). Please read them before you
respond. [For question (2) 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 a person of Cuban,
Mexican,
Puerto Rican, Central or South American, or other Spanish culture
or origin, regardless of race.
YES, Hispanic NO, not Hispanic
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 America
and who maintains cultural identification through tribal
affiliation or community recognition, e.g. Cherokee, Mohawk,
Inuit.
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: 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.
Relationship to Student (please check one box below):
Mother Father Guardian Other (Specify):
___________________________
_________________________________________________________
____________________
Signature of Parent/Guardian/Other Date
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 cited below.
The Family Educational Rights and Privacy Act (1974) prohibit
unauthorized access to student records and unauthorized release
of
any student record information identifiable by either student name
or student identification number.
CONFIDENTIAL PROCEDURES AND REGULATIONS
1 ENGLISH
Dear Parent or Guardian: In order to provide your child with the
best possible education, we need to determine how well he or she
understands, speaks, reads and writes in English, as well as prior
school and personal history. Please complete the sections below
entitled Language Background and Educational History. Your
assistance in answering these questions is greatly appreciated.
Thank you.
STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW
YORK / ALBANY, NY 12234 Office of P-12
Lissette Colón-Collins, Assistant Commissioner
55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB
Brooklyn, New York 11217 Albany, New York 12234
Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax:
(518) 474-7948
Home Language Questionnaire (HLQ)
H O M E L A N G U A G E C O D E
Language Background (Please check all that apply.)
1. What language(s) is(are) spoken in the student’s home or
residence?
English Other
specify
2. What was the first language your child learned? English
Other
_________________________________________ specify
3. What is the Home Language of each parent/guardian? Mother Father
specify specify
Guardian(s) specify
specify
5. What language(s) does your child speak? English Other Does not
speak
specify
6. What language(s) does your child read? English Other Does not
read
specify
7. What language(s) does your child write? English Other Does not
write
specify
TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY
DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS
RREEGGIISSTTEERREEDD::
Please write clearly when completing this section. S T U D E N T N
A M E :
First Middle Last
D A T E O F B I R T H : G E N D E R :
Male Female Month Day Year
P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F
O :
Last Name First Name Relation to Student
S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I
D N U M B E R I N N Y S S T U D E N T
I N F O R M A T I O N S Y S T E M :
District Name (Number) & School Address
2 ENGLISH
Educational History
8. Indicate the total number of years that your child has been
enrolled in school _____________
9. 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:____________________________________________________________________________
How severe do you think these difficulties are? Minor Somewhat
severe Very severe
10a. Has your child ever been referred for a special education
evaluation in the past? No Yes* *Please complete 10b below
10b. *If referred for an evaluation, has your child ever received
any special education services in the past? No Yes – Type of
services received: .
Age at which services received (Please check all that apply):
Birth to 3 years (Early Intervention) 3 to 5 years (Special
Education) 6 years or older (Special Education)
10c. Does your child have an Individualized Education Program
(IEP)? No Yes
11. Is there anything else you think is important for the school to
know about your child? (e.g., special talents, health concerns,
etc.)
12. In what language(s) would you like to receive information from
the school? _________________________________________________
Month: Day: Year:
Signature of Parent or of Person in Parental Relation Date
OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING
HLQ
NAME: POSITION:
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND
CREDENTIALS:
NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING
INDIVIDUAL INTERVIEW
NAME: POSITION:
**DATE OF INDIVIDUAL INTERVIEW:
NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL
NAME: POSITION:
MO. DAY YR.
FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY,
ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE
RECOMMENDATION:
WATERLOO CENTRAL SCHOOL DISTRICT DISTRICT OFFICES
109 WASHINGTON STREET WATERLOO, NEW YORK 13165 STUDENT RECORDS
REQUEST
School Name: (Prior school)
______________________________________________ School Address:
______________________________________________ School City, State,
Zip: ______________________________________________ School
Telephone: ______________________School Fax: ______________________
School Email:
____________________________________________________________
PERMISSION IS HEREBY GIVEN TO WATERLOO CENTRAL SCHOOL DISTRICT TO
RECEIVE INFORMATION REGARDING:
Student Name: __________________________________________
PLEASE SEND A COPY OF THE FOLLOWING:
x Birth Certificate x Achievement Test Scores x Report Card x
Transcript & Attendance Report x Immunization and Health
Records x Discipline Records
PLEASE SEND TO:
______ ______ ______ ______ Shaun Merrill, Principal Vincent
Vitale. Principal Terri Goodman, Guidance Sec. Lafayette
Intermediate School Waterloo Middle School Waterloo Senior High
School 71 Inslee Street 65 Center Street 96 Stark Street Waterloo,
NY 13165 Waterloo, NY 13165 Waterloo, NY 13165 Phone: 315-539-1530
Phone: 315-539-1540 Phone: 315-539-1552 Fax: 315-539-1529 Fax:
315-539-1534 Fax: 315-539-1536 Email: Email: Email:
Sherri Monell, Principal Skoi Yase Primary School 65 Fayette Street
Waterloo, NY 13165 Phone: 315-539-1520 Fax: 315-539-1527 Email:
[email protected] [email protected]
[email protected] [email protected]
___________________________________ ________________ Signature of
Parent/Guardian Date
109 WASHINGTON STREET WATERLOO, NEW YORK 13165 STUDENT RECORDS
REQUEST FOR STUDENTS WITH SERVICES
School Name: (Prior school)
______________________________________________ School Address:
______________________________________________ School City, State,
Zip: ______________________________________________ School
Telephone: ______________________School Fax: ______________________
School Email:
____________________________________________________________
PERMISSION IS HEREBY GIVEN TO WATERLOO CENTRAL SCHOOL DISTRICT TO
RECEIVE INFORMATION REGARDING:
Student Name: __________________________________________
DOB: ___________________ Grade Last Attended: _____________
PLEASE SEND A COPY OF THE FOLLOWING: IEP, 504 Plan or
Declassification Notes Psychological/Psychiatric Evaluations OT,
PT, Speech, Vision, Hearing, etc. Evaluations IEP Goals Progress
Reports OT, PT, Speech Scripts Parental Consent for Special
Education Services Transcripts
PLEASE SEND TO: WATERLOO CSE OFFICE 109 WASHINGTON STREET WATERLOO,
NY 13165 Phone: 315-539-1503 Fax: 315-539-1537
[email protected]
___________________________________ ________________ Signature of
Parent/Guardian Date
Waterloo Central School District
Committee on Special Education
Medicaid Consent
Dear Parent/Guardian:
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.
• 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 Medication Administration Report
Evaluation Reports Other Personally Identifiable Information
Session Notes 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.
Parent/Guardian Signature:
__________________________________________
Print Name: __________________________________________ Date:
____________________
*Please provide your child’s Medicaid CIN# from their personal
Medicaid card: ____________________
(The CIN# is the Alphanumeric ID Number located above the sex and
DOB on your child’s Medicaid card.
It starts with 2 letters, followed by 5 numbers, and ends with 1
letter.)
Waterloo Central School District DISTRICT OFFICES 109 Washington
Street Waterloo, NY 13165
STUDENT HEALTH INFORMATION
Student Name__________________________________ School____________
*New registrants are required by law to provide the school with a
Health Examination form completed by the child’s physician and a
Dental Health form completed by the child’s dentist within the past
12 months. PLEASE CHECK ONE: ____ I will provide the school’s
Health office with the completed health and dental forms within the
next 30 days. (Please note: IF THE REQUIRED FORMS ARE NOT RECEIVED
BY THE SCHOOL DISTRICT IN THE 30 DAYS, THE SCHOOL PHYSICIAN WILL
COMPLETE THE EXAM WITHOUT FURTHER NOTIFICATION TO THE
PARENT/GUARDIAN.) ____ The school physician may conduct my child’s
physical examination. If you are unable to provide us with this
current health information then our school physician (Life Care
Medical Associates) with perform a physical examination for your
child in the school’s health office, during school hours, at no
cost to you. You would be informed of any health concerns related
to this physical examination via a medical screening referral form.
Signature of Parent/Guardian______________________ Date___________
I give permission for the school nurse to share any pertinent
medical information with other school personnel on a need to know
basis. Signature of Parent/Guardian______________________
Date___________
Student’s Doctor: _________________________ Phone: ____________
Student’s Dentist: _________________________ Phone:
____________
Last updated 11/19/17
Please have your health care provider send health forms to your
child’s school: Waterloo High School 96 Stark St. Waterloo, NY
13165 phone 315-539-1555 fax 315-539-1536 Waterloo Middle School 65
Center St. Waterloo NY 13165 phone 315-539-1545 fax 315-539-1534
Lafayette Intermediate School 71 Inslee St. Waterloo, NY 13165
phone 315-539-1535 fax 315-539-1529 Skoi Yase Primary School 65
Fayette St. Waterloo, NY 13165 phone 315-539-1525 fax
315-539-1527
STUDENT HEALTH INFORMATION (Page 2)- Student DOB___________
Child’s Medical History
Illness Date Illness Date TB/Contact with TB _____ Lead Poisoning
_____ Head Injury/concussion _____ Asthma _____ Anxiety _____
ADD/ADHD _____ Depression _____ Bipolar _____ Sickle Cell Anemia
_____ ODD/OCD _____ Whooping cough _____ Autism/Asperger _____
Meningitis _____ Heart Disease/Murmur _____ Chicken Pox _____
Diabetes _____ Pneumonia _____ Kidney Disease _____ Recurrent Sore
Throats Seizure Disorder _____ and/or Ear infections _____ Bleeding
Disorder _____ Other illness or disease _____ Missing Organs
_____
Explanation of any of the above listed illnesses:
____________________________________________________________
____________________________________________________________
Does your child have any allergies? YES NO If yes, please
list_________________
Is your child taking any medications? YES NO If yes, please
list_______________
Does your child have EMERGENCY medication they may need at school?
YES NO If yes, please list________________________________
Have you ever suspected that your child may have poor eyesight? YES
NO If so, has he/she ever been seen by an optometrist or eye
specialist? YES NO If so, what were the results?
________________________________________
Have you ever suspected that your child may have a hearing problem?
YES NO If so, has he/she been evaluated by a doctor: YES NO If so,
what were the results?
________________________________________
Have you suspected that your child may have a speech or language
problem? YES NO If so, has he/she had a speech or language
evaluation: YES NO If so, what were the results?
_________________________________________
Has your child had any other screenings or evaluations? YES NO
(psychological, educational, allergy testing, physical therapy,
occupational therapy, etc.) If so, what were the results?
_________________________________________
Has your child been hospitalized? YES NO If so, please explain?
_____________________________________________
Has your child ever seen a dentist? YES NO If so, for what reasons?
__________
Is there any condition that limits classroom or physical education
activities: YES NO If so, please explain?
_____________________________________________
STUDENT HEALTH INFORMATION (Page 3)- Student Name___________ Other
Medical issues that you would like to bring to the school’s
attention:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
_____________ ______________________________________ Date Signature
of Parent / Guardian
Last updated 11/22/19
2020-2021 Application for Free and Reduced Price School Meals
To apply for free and reduced-price meals for your children, read
the instructions on the back, complete only one form for your
household, sign your name and return it to the address listed
below. Call 315-539-1464, if you need help. Additional names may be
listed on a separate paper.
Return Completed Applications to: WATERLOO CENTRAL SCHOOL DISTRICT
96 STARK STREET WATERLOO, NY 13165 ATTN: BRIAN COREY
1. List all children in your household who attend school:
Student Name School Grade/Teacher
2. SNAP/TANF/FDPIR Benefits: If anyone in your household receives
either SNAP, TANF or FDPIR benefits, list their name and CASE #
here. Skip to Part 4 and sign the application. Name:
______________________________________ CASE #:
__________________________________Must list a Valid Case # for
application to be approved
3. Report all income for ALL Household Members (Skip this step if
you answered ‘yes’ to step 2) All Household Members (including
yourself and all children that have income). List all Household
members not listed in Step 1 (including yourself) even if they do
not receive income. For each Household Member listed, if they do
receive income, report total income for each source in whole
dollars only. If they do not receive income from any other source,
write ‘0’. If you enter ‘0’ or leave any fields blank, you are
certifying (promising) that there is no income to report.
Name of household member Earnings from work before deductions
Amount / How Often
Child Support, Alimony Amount / How Often
Pensions, Retirement Payments Amount / How Often
Other Income, Social Security Amount / How Often
No Income
*Last Four Digits of Social Security Number: XXX-XX- __ __ __
__
*When completing section 3, an adult household member must provide
the last four digits of their Social Security Number (SS#) or mark
the “I do not have a SS# box” before the application can be
approved.
4. Signature: An adult household member must sign this application
before it can be approved. I certify (promise) that all the
information on this application is true and that all income is
reported. I understand that the information is being given so the
school will get federal funds; the school officials may verify the
information and if I purposely give false information, I may be
prosecuted under applicable State and federal laws, and my children
may lose meal benefits. Signature:
___________________________________________________ Date:
___________________ Email Address:
________________________________________________ Home Phone:
_____________________ Work Phone: _________________________ Home
Address:____________________________________________
5. Ethnicity and Race are optional; responding to this section does
not affect your children’s eligibility for free or reduced-price
meals.
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race:(Check one or more) American Indian or Alaskan Native Asian
Black or African American Native Hawaiian or Other Pacific Island
White
DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLY
Annual Income Conversion (Only convert when multiple income
frequencies are reported on application)
Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X
24; Monthly X 12
SNAP/TANF/Foster
Free Meals Reduced Price Meals Denied/Paid Signature of Reviewing
Official________________________________________________________
Date Notice Sent:________________
I do not have a
SS#
2
APPLICATION INSTRUCTIONS
To apply for free and reduced price meals, complete only one
application for your household using the instructions below. Sign
the application and return the application to, WATRLOO CSD, 96
STARK ST., WATERLOO NY 13165. ATTN: FOOD SERVICE DEPT. If you have
a foster child in your household, you may include them on your
application. A separate application is not needed. Call the school
if you need help: 315-539-1464. Ensure that all information is
provided. Failure to do so may result in denial of benefits for
your child or unnecessary delay in approving your
application.
PART 1: ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT
FILL OUT MORE THAN ONE APPLICATION FOR YOUR HOUSEHOLD. (1) Print
the names of the children, including foster children, for whom you
are applying on one application. (2) List their grade and school.
(3) Check the box to indicate a foster child living in your
household, or if you believe any child meets the description for
homeless, migrant, runaway (a school staff will confirm this
eligibility). PART 2 HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD
COMPLETE PART 2 AND SIGN PART 4. (1) List a current SNAP, TANF or
FDPIR (Food Distribution Program on Indian Reservations) case
number of anyone living in your household. The case number is
provided on your benefit letter. Contact your local Dept of Social
Services to obtain your valid case number. (2) An adult household
member must sign the application in PART 4. SKIP PART 3. Do not
list names of household members or income if you list a SNAP case
number, TANF or FDPIR number. PART 3 ALL OTHER HOUSEHOLDS MUST
COMPLETE THESE PARTS AND ALL OF PART 4. (1) Write the names of
everyone in your household, whether or not they get income. Include
yourself, the children you are applying for, all other
children,
your spouse, grandparents, and other related and unrelated people
in your household. Use another piece of paper if you need more
space. (2) Write the amount of current income each household member
receives, before taxes or anything else is taken out, and indicate
where it came from, such
as earnings, welfare, pensions and other income. If the current
income was more or less than usual, write that person’s usual
income. Specify how often this income amount is received: weekly,
every other week (bi-weekly), 2 x per month, monthly. If no income,
check the box. The value of any child care provided or arranged, or
any amount received as payment for such child care or reimbursement
for costs incurred for such care under the Child Care and
Development Block Grant, TANF and At Risk Child Care Programs
should not be considered as income for this program.
(3) Enter the total number of household members in the box
provided. This number should include all adults and children in the
household and should reflect the members listed in PART 1 and PART
3.
(4) The application must include the last four digits only of the
social security number of the adult who signs PART 4 if Part 3 is
completed. If the adult does not have a social security number,
check the box. If you listed a SNAP, TANF or FDPIR number, a social
security number is not needed.
(5) An adult household member must sign the application in PART 4.
OTHER BENEFITS: Your child may be eligible for benefits such as
Medicaid or Children’s Health Insurance Program (CHIP). To
determine if your child is eligible, program officials need
information from your free and reduced price meal application. Your
written consent is required before any information may be released.
Please refer to the attached parent Disclosure Letter and Consent
Statement for information about other benefits.
USE OF INFORMATION STATEMENT Use of Information Statement: The
Richard B. Russell National School Lunch Act requires the
information on this application. You do not have to give the
information, but if you do not submit all needed information, we
cannot approve your child for free or reduced price meals. You must
include the last four digits of the social security number of the
primary wage earner or other adult household member who signs the
application. The social security number is not required when you
apply on behalf of a foster child or you list a Supplemental
Nutrition Assistance Program (SNAP), Temporary Assistance for Needy
Families (TANF) Program or Food Distribution Program on Indian
Reservations (FDPIR) case number or other FDPIR identifier for your
child or when you indicate that the adult household member signing
the application does not have a social security number. We will use
your information to determine if your child is eligible for free or
reduced price meals, and for administration and enforcement of the
lunch and breakfast programs. We may share your eligibility
information with education, health, and nutrition programs to help
them evaluate, fund, or determine benefits for their programs,
auditors for program reviews, and law enforcement officials to help
them look into violations of program rules.
DISCRIMINATION COMPLAINTS
In accordance with Federal civil rights law and U.S. Department of
Agriculture (USDA) civil rights regulations and policies, the USDA,
its Agencies, offices, and employees, and institutions
participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, sex,
disability, age, or reprisal or retaliation for prior civil rights
activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of
communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency
(State or local) where they applied for benefits. Individuals who
are deaf, hard of hearing or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in
languages other than English. To file a program complaint of
discrimination, complete the USDA Program Discrimination Complaint
Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any
USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a
copy of the complaint form, call (866) 632- 9992. Submit your
completed form or letter to USDA by: (1) mail: U.S. Department of
Agriculture
Office of the Assistant Secretary for Civil Rights 1400
Independence Avenue, SW Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or (3) email:
[email protected].
This institution is an equal opportunity provider.
Residency Questionnaire waterloo
New Student Registration Request For Transportation-2019
pre k-k student input form
Sheet1
CSE Records Request Form 11-1-19
CSE info 6-18
medicaid consent waterloo
STUDENT HEALTH INFORMATION
STUDENT HEALTH INFORMATION
2018-2019 free-reduce application
Child’s Medical History
UPK Page for registation.pdf
Grade Level:
Text141:
Text142:
Text143:
Text144:
S T U D E N T N A M E Row1:
First Middle Last:
G ENDER:
D A T E O F B I R T H Row1:
undefined_40: Off
Male Female:
P A R E N T P E R S O N I N P A R E N T A L R E L A T I O N I N F O
Row1:
English: Off
Other_3: Off
Other_4: Off
English_2: Off
specify_4:
S C H O O L D I S T R I C T I N F O R M A T I O N Row1:
S T U D E N T ID N U M B E R I N NYS S T U D E N T I N F O R M A T
I O N S Y S T E M Row1:
8 Indicate the total number of years that your child has been
enrolled in school:
If yes please explain:
Age at which services received Please check all that apply:
No_7: Off
Birth to 3 years Early Intervention: Off
3 to 5 years Special Education: Off
6 years or older Special Education: Off
10c Does your child have an Individualized Education Program IEP:
Off
11 Is there anything else you think is important for the school to
know about your child eg special talents health concerns
etcRow1:
11 Is there anything else you think is important for the school to
know about your child eg special talents health concerns
etcRow2:
12 In what languages would you like to receive information from the
school:
Mother_2: Off
Father_2: Off
Other_9: Off
OUTCOME OF INDIVIDUAL INTERVIEW ADMINISTER NYSITELL ENGLISH
PROFICIENT REFER TO LANGUAGE PROFICIENCY TEAM:
NAME_3:
ADMINISTRATION:
Session NotesRow1:
Any Other Specific Records Pertaining to the Students Services or
ProgramRow1:
ParentGuardian Signature 2:
Date_10: