Student Registration Form - Mahopac Central School District

MAHOPAC CENTRAL SCHOOL DISTRICT
REGISTRAR
Student Registration Form
Please print legibly with blue or black ink
STUDENT LAST NAME ___________________________________________________ FIRST NAME _____________________________________ MI _________
HOME ADDRESS ____________________________________________ _______________________________ NEAREST CROSSROAD__________________
City
MAILING ADDRESS (if different) _____________________________________________________________________
DATE OF BIRTH ___________________
LOCATION OF BIRTH: CITY ________________________ STATE __________________ GENDER: Male / Female
Country of Birth if not the U.S.: ________________________________________ Date of Entry in U.S.: ______________________
Date of Entry in U.S. Schools: ______________
ARE SPECIAL SERVICES REQUIRED: English Language Learner / ESOL 1 : Yes / No Special Education / IEP 2 : Yes / No
HISPANIC: ___Yes ___ No
African American Native Hawaiian/
ETHNICITY: _____ Asian _____ American _____ Indian _____ Other Pacific Islander _____White
If more than one ethnicity applies, please indicate as follows: primary ( 1 ), secondary ( 2 ), etc.
TRANSFER FROM: School Name ______________________________________________ City & State ________________________________
FOR GRADE K REGISTRATION, PRE-SCHOOL ATTENDED ____________________________________________________________________
PARENT/GUARDIAN INFORMATION:
Marital Status: ___ Married ___ Single ___ Widowed ___ Divorced CUSTODY ISSUES 3 : Yes / No
Student Resides With: ___ Father ___ Mother ___ Both ___ Step Father ___ Step Mother
___ Foster Parents 4 ___ Legal Guardian 4 ___Other _______________(please explain)
If student resides with Foster Parents or Legal Guardian, supporting documentation will be required (see Parent & Custodial Affidavits)
Name ________________________________ ___Father ___Step Father ___Legal Guardian _________________Other
Employer/Occupation ___________________________ _______________________ E-Mail Address: ___________________________
Home Phone ( )_________________ Business Phone ( )__________________ Cell ( )_____________________
Work Location: City & State __________________ Hours: _____ to _____ Work Days: __Mon __Tues __Wed __Thurs __Fri
Name ________________________________ ___Mother ___Step Mother ___Legal Guardian _________________Other
Employer/Occupation ___________________________________________________ E-Mail Address: ___________________________
Home Phone ( )_________________ Business Phone ( )__________________ Cell ( )_____________________
Work Location: City & State __________________ Hours: _____ to _____ Work Days: __Mon __Tues __Wed __Thurs __Fri
Name ________________________________ __Parent __Step Parent ___Legal Guardian _________________Other
Employer/Occupation ___________________________________________________ E-Mail Address: __________________________
Parent Mailing Address (if different from Student): _____________________________________________________________________
_______________________________________________
Parent requests extra mailings: ___Yes ___ No
Home Phone ( )________________ Business Phone ( )__________________ Cell ( )______________________
Work Location: City & State __________________ Hours: _____ to _____ Work Days: __Mon __Tues __Wed __Thurs __Fri
I (We) affirm that the information provided on this form is true and correct. I (We) understand that the District may investigate any
allegation contained in this form and may ask for written proof of any statement. In order to verify the information or statements
provided on this form (including any supporting documents and affidavits), I (we) give consent for the release of this form
(including any supporting documents and affidavits) or any information contained in this form to Mahopac Central School District,
the landlord, or any other third party in furtherance of the School District’s investigation. I (We) understand that if the allegations
contained in this form (including supporting documents and affidavits) are determined not to be true and accurate, I (we) will be
held responsible for the payment of tuition to the District.
______________________________________
Parent/Guardian Signature
_______________________
Date
TO BE COMPLETED BY SCHOOL PERSONNEL ENTER DATE __________ ENTER CODE ______ SCHOOL CODE __________
STUDENT ID NO. ____________________ FAMILY NO. _______________
MAP CODE __________ GRADE _________
PROOF OF - BIRTH: ___ Birth Certificate ___Green Card ___Passport IMMUNIZATION: Yes / No
BUS NO. TO _______ BUS NO. FROM _______
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MAHOPAC CENTRAL SCHOOL DISTRICT
REGISTRAR
Mahopac Central School District – Student Registration Form
BROTHERS & SISTERS (Include All Children Living With Family):
EXPECTED TO
DATE CURRENT ATTEND MCSD
NAME (First & last) OF BIRTH SCHOOL GRADE GENDER IF YES – START DATE FOR MCSD USE
ARE THERE ANY SIBLINGS UNDER THE AGE OF FIVE WITH SPECIAL NEEDS _____ Yes _____ No
EMERGENCY CONTACT INFORMATION: In case of an emergency, the parent/guardians listed on page one of this form are the first to be
contacted. In the event you cannot be reached, please list below three additional contacts. Please include their city and state in order to assist us in
determining the contact in closest proximity to the school. The individuals below have the authorization to pick up your child in the event you cannot be
reached.
RELATIONSHIP
TELEPHONE NUMBER TO STUDENT CITY & STATE
CONTACT(1): _______________________________ ( ) _________________ ______________________ ____________________
CONTACT(2): _______________________________ ( ) _________________ ______________________ ____________________
CONTACT(3): _______________________________ ( ) _________________ ______________________ ____________________
PHYSICIAN: ____________________________________________ TEL: ( ) _______________________________
IF I WISH TO CHANGE THE DOCTOR INDICATED ABOVE, IT IS MY RESPONSIBILITY TO NOTIFY THE SCHOOL NURSE OF THIS CHANGE.
EMERGENCY MEDICAL CARE CONSENT
In the event of an accident, sudden illness, or other cause which, in the judgment of the school nurse or other person in charge, requires advice or
treatment beyond general aid, I give permission for an ambulance to be called to transport my child to the nearest hospital. Furthermore, I give
permission to the hospital to treat my child. I understand that every effort will be made to contact me if the above circumstances should occur.
I recognize that when the school calls for assistance in this way, it is acting on my behalf, and that any medical care that my youngster receives is the
financial obligation of myself and not the school.
______________________________________
Parent/Guardian Signature
_______________________
Date
Note: As a procedure the school will ask parents to keep their child(ren) home from school if they show any sign of significant infection. If your child
has had a fever (100 F. or above) he/she should not return to school until his/her temperature has been normal for at least 24 hours. Please have any
body rash or eye inflammation checked by your doctor to determine whether or not it is contagious.
If a child requires any medication during school hours, the medication should be brought to the School Nurse by the parent or a responsible adult. It
must be in the original prescription bottle with a permission form completed by the parent and doctor and signed by the parent/guardian. Students are
not to bring medication (including over the counter medications such as Tylenol) with them.
______________________________________
Parent/Guardian Signature
_______________________
Date
NOTES TO BUILDING REGISTRAR:
1 Country & Home Language Survey to be completed and forwarded to the ESOL teacher.
2 Completed Special Education Registration Documents to Special Education.
3 See Registration procedures for Custody Issues.
4 Requires completion of Custodial Affidavit and Parent Affidavit
DOCUMENTATION PENDING (Please initial) ___________
REGISTRAR’S NAME & INITIALS __________________________ _______
P:\Tech Share\Registration\Student Registration Form-Revision.doc (Revised 5/17/2007)
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