REGISTRATION CHECKLIST (Grades 1-5)

MELROSE PUBLIC SCHOOLS REGISTRATION CHECKLIST (Grades 1-5) CHILD’S NAME:___________________________________________________________ Last First Middle The grade you are registering for: ______________ GENDER: (choose only one) MALE FEMALE NON-BINARY ___ COMPLETED REGISTRATION FORM All fields must be completed. If something does not apply to you please enter “NO” or “N/A” ___ BIRTH CERTIFICATE Original document with seal must be presented We will make a copy for our file and return the original back to you ___ Current Proof of Residency See attached Residency Procedures and Forms. These documents must be original documents mailed from the bill source, not a fax or printout from an online billing/payment center We will make copies for our files and return the originals back to you ___ Home Language Survey ___ Current physical exam and immunizations Must be within the past 12 months We will accept a copy ___RELEASE OF STUDENT RECORDS FORM ___ATTENDANCE REPORT ___DISCIPLINE REPORT ___CONFIDENTIAL STUDENT HEALTH & EMERGENCY INFORMATION FORM 11.18 MELROSE PUBLIC SCHOOLS REGISTRATION FORM Office Use Only: Date Rec’d____________ Year of Graduation ____________________ STUDENT INFORMATION GRADE________ STUDENT NAME________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME GENDER: (choose only one) MALE FEMALE NON BINARY STUDENT BIRTH DATE _______________ mm-dd-yyyy PLACE OF BIRTH (city) _________________COUNTRY OF ORIGIN (where child was born) _________________ RACE/ETHNICITY(choose one) Hispanic Not Hispanic CHOOSE ALL THAT APPLY: White/Caucasian Black/African American Asian Native American Native Hawaiian/Pacific Islander NATIVE LANGUAGE__________________ INDIVIDUAL EDUCATION PLAN (IEP) DOES THE STUDENT CURRENTLY RECEIVE SERVICES ON AN IEP? YES NO 504 ACCOMMODATION PLAN DOES THE STUDENT CURRENTLY RECEIVE SERVICES ON A 504? YES NO DOES THE CHILD’S FAMILY HAVE A MILITARY AFFILIATION? YES NO IF YES, PLEASE SELECT FROM THE FOLLOWING: ACTIVE DUTY DIED ON ACTIVE DUTY VETERAN WHO IS MEDICALLY DISCHARGED OR RETIRED FOR ONE (1) YEAR STUDENT RESIDENCE INFORMATION PARENT/GUARDIAN NAME _______________________________________________________________________ FULL NAME(S) OF PARENT / GUARDIAN FOR MAILING ADDRESS LABELS STREET ______________________________________________________________________________________ CITY ______________ STATE _______ ZIP ____________ PRIMARY PHONE (required) ______________________ PARENT/GUARDIAN CONTACT INFORMATION CONTACT 1 (PARENT/GUARDIAN) NAME________________________________________________________________________________________ STREET ______________________________________________________________________________________ CITY ________________________________STATE _____________________ ZIP CODE ____________________ PRIMARY PHONE ____________________________MOBILE PHONE NUMBER ___________________________ PHONE 2 ___________________________________PHONE 3 _________________________________________ EMAIL ADDRESS _______________________________________________________________________________ EMPLOYER ________________________________________RELATIONSHIP TO STUDENT__________________ CONTACT 2 (PARENT/GUARDIAN) NAME_________________________________________________________________________________________ STREET ______________________________________________________________________________________ CITY ________________________________STATE _____________________ ZIP CODE ____________________ PRIMARY PHONE ____________________________MOBILE PHONE NUMBER ___________________________ PHONE 2 ___________________________________PHONE 3 __________________________________________ EMAIL ADDRESS _______________________________________________________________________________ EMPLOYER ______________________________________RELATIONSHIP TO STUDENT ____________________ GUARDIAN STATUS (SEE ATTACHED) YES NO STATE WARD STATUS (SEE ATTACHED) YES NO EMERGENCY CONTACT INFORMATION THIS CONTACT MUST BE SOMEONE OTHER THAN A PARENT/GUARDIAN NAME __________________________________________________ HOME PHONE _______________________ CELL PHONE ___________________________________RELATIONSHIP TO STUDENT______________________ SCHOOL CHOICE: In order to best meet the needs of its elementary school children, Melrose Public Schools has adopted Policy JC: Elementary School Assignment and Class Size Policy (see attached). The goal is to provide equitable class size throughout the district as well as the smallest class size possible for children in our elementary schools. Please mark only one selection per row: 1ST CHOICE Hoover Horace Mann Lincoln Roosevelt Winthrop 2ND CHOICE Hoover Horace Mann Lincoln Roosevelt Winthrop 3RD CHOICE Hoover Horace Mann Lincoln Roosevelt Winthrop SIBLINGS: We are only concerned with siblings who are currently in an elementary school in Melrose Public Schools. Siblings who attend Melrose Middle School or High School are not considered a factor in the placement of a younger sibling. Please indicate the first and last names of your other children, the grade and school they will attend in September. Sibling name; ____________________________ Grade: _____________ School: ___________________________ Sibling name; ____________________________ Grade: _____________ School: ___________________________ Sibling name; ____________________________ Grade: _____________ School: ___________________________ “CONNECT-ED INFORMATION* – WHAT IS CONNECT-ED? (SEE ATTACHED) DO YOU WANT TO PARTICIPATE IN CONNECT-ED? YES NO If you answered “yes”, the Contact 1 and Contact 2 primary phone number and email address will be used. MEDIA RELEASE – PERMISSION (SEE ATTACHED) select one: Unrestricted Use Limited Use Deny Use PTO DIRECTORY INFORMATION May we share your contact information with the school’s PTO? YES NO If you answered “yes”, the information provided in the Student Residence Information section will be shared with the PTO. Home Language Survey Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance. Student Information First Name Middle Name Last Name Gender F M NB / / / __/ ______ Country of Birth Date of Birth (mm/dd/yyyy) Date first enrolled in ANY U.S. school (mm/dd/yyyy) Sc hool Information / /20 Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade Questions for Parents/Guardians What is the native language(s) of each parent/guardian? (circle one) Which language(s) are spoken with your child? (include relatives -grandparents, uncles, aunts,etc. - and caregivers) (mother / father / guardian) seldom / sometimes / often / always (mother / father / guardian) seldom / sometimes / often / always What is the native language of your child? Which language do you use most with your child? Which other languages does your child know? (circle all that apply) Which languages does your child use? (circle one) speak / read / write seldom / sometimes / often / always speak / read / write seldom / sometimes / often / always Is your child able to complete class work in English? Will you require written information from school in your native language? Y N Y N Will you require an interpreter/translator at Parent-Teacher meetings? Y N Parent/Guardian Signature: / /20_____ X Today’s date: (mm/dd/yyyy) Rev. 1/2012 Melrose Public Schools 360 LYNN FELLS PARKWAY, MELROSE, MA 02176 Telephone: (781) 662-2000 V/TTY FAX: (781) 979-2149 Release of Student Records/Transfer Student – New to Melrose To: _____________________________________________________________________________________________ (Name of previous school) _____________________________________________________________________________________________ (Street Address, City, State, Zip) _________________________________________ ____________________________________ (Telephone) (Fax) _________________________________________ ____________________________________ (Student Name) (Date of Birth) The student referenced above has transferred to the Melrose Public Schools. Please forward all records relevant to the educational needs of the student to: ____________________________________________________ (Name of School) ______________________________________________________________ (Street Address, City, State, Zip) _________________________ __________________________ Telephone Number Fax Number Attention: ___________________________________________ _____ Student Transfer Card (including SASID #) _____ Permanent Student Records _____ Scholastic Records (including standardized test scores) _____ Health Records (including recent physical and immunizations) _____ Special Education Special Education and/or 504 Records _____ Disciplinary Records ******************************************************************************************* I hereby authorize the release of all information and records in the school files pertaining to the above named student. Name of Parent/Legal Guardian: _____________________________________Date: ________ (Please print) Signed: _______________________________ Relationship to Child: _____________________

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