STUDENT’S NAME _____________________________________ HOME PHONE NUMBER: _____________________________

ADDRESS _____________________________________________ PRIMARY CELL PHONE NUMBER: _____________________

_____________________________________________ PRIMARY PAGER NUMBER: ___________________________

DATE OF BIRTH: ________________ Male ___ Female ___ BIRTHPLACE: ________________________________________

STUDENT’S SOCIAL SECURITY #_________________________ (OPTIONAL)

HOW LONG DO YOU INTEND TO RESIDE IN THE AREA? ________________________________________________________

CHILD’S SIBLINGS:

_____________________________ ____________________ ______________________________ ____________________

NAME DATE OF BIRTH NAME DATE OF BIRTH

_____________________________ ____________________ ______________________________ ___________________

NAME DATE OF BIRTH NAME DATE OF BIRTH

HAS YOUR CHILD ATTENDED PRE-SCHOOL? ____ FULL DAY ____ HALF-DAY ____ PUBLIC ____ PRIVATE

HAS YOUR CHILD ATTENDED KINDERGARTEN? ____ FULL DAY ____ HALF-DAY ____ PUBLIC ____ PRIVATE

NAME OF LAST PRE-SCHOOL/SCHOOL ATTENDED? __________________________________DATES ATTENDED ___________

ADDRESS (INCLUDE CITY, STATE, ZIP) ___________________________________________________________________________

MY CHILD WILL BE ENTERING GRADE______ IF HELD BACK, NOTE GRADE AND YEAR ______________________________

HAS YOUR CHILD BEEN EVALUATED FOR OR RECEIVED ANY SUPPORT SERVICES? _____ YES _____ NO

IF YES, PLEASE CHECK ANY AREA(S) IN WHICH YOUR CHILD IS CURRENTLY RECEIVING SERVICE(S):

____ READING ____ MATH ____ SPEECH _____ RESOURCE ____ SPECIAL ED ____ OTHER (PLEASE NOTE) ___________

HAS YOUR CHILD BEEN EVALUATED FOR/PARTICIPATED IN A PROGRAM FOR GIFTED STUDENTS? _____YES ____ NO

PLEASE LIST BELOW THE NAME OF THE PARENT(S) WITH WHOM THE STUDENT RESIDES.

MOTHER _______________________________________________ FATHER ___________________________________________

CHECK ONE: … PARENT … STEP PARENT CHECK ONE: … PARENT … STEP PARENT

OCCUPATION __________________________________________ OCCUPATION ______________________________________

EMPLOYER ____________________________________________ EMPLOYER ________________________________________

EMPLOYER’S ADDRESS _________________________________ EMPLOYER’S ADDRESS ____________________________

EMPLOYER’S PHONE NO. ________________________________ EMPLOYER’S PHONE NO. __________________________

ADM-01-01

STUDENT’S NAME ____________________________________________

IF YOUR CHILD IS RESIDING WITH ONLY ONE PARENT, AND THE OTHER PARENT IS LIVING, PLEASE LIST THE NAME OF THE NON-CUSTODIAL PARENT BELOW.

NAME ________________________________________________________ IS THERE A NO CONTACT ORDER IN EFFECT?

ADDRESS _____________________________________________________ YES ____ NO ____

HOME PHONE NO. _____________________________________________ IF YES, DOCUMENTATION MUST BE PROVIDED.

OCCUPATION _________________________________________________

EMPLOYER ___________________________________________________ EMPLOYER’S PHONE NO. ________________________

EMPLOYER’S ADDRESS (INCLUDE CITY, STATE, ZIP) _________________________________________________________________

PLEASE LIST THE NAME OF SOMEONE TO BE CONTACTED IN THE EVENT MOTHER OR FATHER CANNOT BE REACHED. (THIS PERSON MUST BE LOCAL AND WILLING TO PICK-UP YOUR CHILD AT SCHOOL AND ASSUME RESPONSIBILITY IN THE CASE OF ILLNESS OR INJURY.)

NAME ________________________________________________________ PHONE NUMBER ___________________________________

ADDRESS ____________________________________________________ RELATIONSHIP TO CHILD ___________________________

HEALTH HISTORY PLEASE CHECK ALL OF THE FOLLOWING CONDITIONS THAT APPLY TO YOUR CHILD:

 ALLERGIES … FRACTURES … SEIZURE DISORDERS

Does child carry Epi Pen? … Yes … No Does child take medication? … Yes … No

… ASTHMA … VISION DIFFICULTIES … CURRENTLY ON MEDICATION

Does child use inhaler? … Yes … No Please list all medications:

… CHICKEN POX … HEARING DIFFICULTIES _________________________________

Date of Disease _________________

… DIABETES … HEADACHES _________________________________

… ECZEMA … OPERATIONS _________________________________

… EMOTIONAL PROBLEMS … HEART CONDITIONS _________________________________

… ADD/ADHD … PHYSICAL HANDICAP _________________________________

Does child take medication? … Yes … No

IF YOU CHECKED ANY OF THE ABOVE CONDITIONS, PLEASE EXPLAIN BRIEFLY AND PROVIDE DATES IF RELEVANT. ALSO, DESCRIBE ANY OTHER HEALTH HISTORY OF WHICH WE SHOULD BE AWARE AND ANY NECESSARY DETAILS REGARDING MEDICATIONS THAT YOUR CHILD TAKES ON A REGULAR BASIS.

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HEALTH INFORMATION RHODE ISLAND STATE LAW REQUIRES THAT ALL STUDENTS ENTERING A PUBLIC SCHOOL MUST FURNISH EVIDENCE THAT THE CHILD HAS BEEN IMMUNIZED AGAINST DIPTHERIA, PERTUSSIS, TETANUS, MEASLES, MUMPS, RUBELLA, POLIO, HEPATITIS B, AND CHICKEN POX. IN ADDITION A LEAD SCREENING MUST HAVE BEEN PERFORMED IF THE CHILD IS ENTERING KINDERGARTEN. A DENTAL EXAMINATION IS RECOMMENDED.

CHILD’S PHYSICIAN __________________________________________ PHONE NUMBER ____________________________________

CHILD’S DENTIST ____________________________________________ PHONE NUMBER ____________________________________

VERIFICATION I VERIFY, TO THE BEST OF MY KNOWLEDGE, THAT MY CHILD IS ABLE TO PARTICIPATE IN ALL THE REGULAR SCHOOL ACTIVITIES. IF NOT, I WILL BRING A STATEMENT, FROM THE CHILD’S PHYSICIAN. THIS STATEMENT SHALL VERIFY THAT THE FOLLOWING LIMITATIONS ARE NECESSARY:

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SIGNATURE _____________________________________________________ RELATIONSHIP ___________________________________

DATE _______________________