REGUSTRATION FORM

REGISTRATION FORM

01/00

PORTSMOUTH SCHOOL DEPARTMENT

PORTSMOUTH, RHODE ISLAND

FOR OFFICE USE ONLY

STUDENT ID# ________________________________________ IMMUNIZATION RECORD ATTACHED? _______________

SCHOOL _____________________________________________ BIRTH CERTIFICATE ATTACHED? ___________________

REGISTRATION DATE ________________________________ TEACHER __________________________________________

ADMISSION DATE ____________________________________ ENTERING GRADE __________________________________

REGISTRAR ______________________________________

SEX:

STUDENT’S NAME _____________________________________ DATE OF BIRTH _______________________ M___ F____

ADDRESS _____________________________________________ BIRTHPLACE _____________________________________

_____________________________________________ PHONE NUMBER _________________________________

UNLISTED NO. KEPT CONFIDENTIAL

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

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

NAME OF LAST SCHOOL OR PRE-SCHOOL ATTENDED? _______________________________________________________

ADDRESS (INCLUDE CITY, STATE, ZIP) _______________________________________DATES ATTENDED ______________

GRADE ENTERING ______ IF HELD BACK, NOTE GRADE AND YEAR ____________________________________________

PLEASE CHECK BELOW ANY AREA IN WHICH YO UR CHILD HAS RECEIVED OR BEEN EVALUATED FOR SERVICES.

READING ____ MATH ____ RESOURCE ____ SPECIAL EDUCATION ____ OTHER ________________________

IS YOUR CHILD RECEIVING SPEECH THERAPY? YES ____ NO ____

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 ___________________________________________

PARENT _____________ STEP PARENT ___________________ PARENT ________________ STEP PARENT _____________

OCCUPATION __________________________________________ OCCUPATION ______________________________________

EMPLOYER ____________________________________________ EMPLOYER ________________________________________

EMPLOYER’S ADDRESS _________________________________ EMPLOYER’S ADDRESS ____________________________

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

PLEASE COMPLETE REVERSE SIDE OF THIS FORM.

STUDENT’S NAME ____________________________________________

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

NAME ____________________________________________ DOES THIS PARENT HAVE ANY CUSTODIAL JURISDICTION?

ADDRESS _________________________________________ YES ____ NO ____

OCCUPATION _____________________________________ IF NO, PLEASE PROVIDE THE SCHOOL WITH DOCUMENT-

ED EVIDENCE NEGATING HIS/HER RIGHTS.

EMPLOYER _______________________________________ I.E. DIVORCE DECREE

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

EMPLOYER’S PHONE NO. ___________________________ HOME PHONE NO. _____________________________________

CHILD’S HEALTH HISTORY CHECK YES OR NO TO EACH OF THE FOLLOWING CONDITIONS:

YES NO YES NO YES NO

ALLERGIES FRACTURES RHEUMATIC FEVER

ASTHMA GLASSES SEIZURE DISORDER

CHICKEN POX HEADACHES SPEECH DIFFICULTIES

DIABETES HEARING DIFFICULTIES TUBERCULOSIS

ECZEMA SURGERY

EMOTIONAL PROBLEMS HEART CONDITIONS

ADD/ADDH PHYSICAL HANDICAP

IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE EXPLAIN AND PROVIDE DATES. ALSO, PLEASE DESCRIBE ANY OTHER HEALTH HISTORY OF WHICH WE SHOULD BE AWARE AND /OR MEDICATIONS THAT YOUR CHILD TAKES ON A REGULAR BASIS.

____________________________________________________________________________________________________________

PLEASE LIST THE NAME OF SOMEONE TO BE CONTACTED IN THE EVENT MOTHER OR FATHER CANNOT BE REACHED. (THIS PERSON MUST BE 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 ___________________________

IMMUNIZATIONS RHODE ISLAND STATE LAW REQUIRES THAT ALL STUDENTS ENTERING A PUBLIC OR PRIVATE SCHOOL MUST FURNISH EVIDENCE THAT THE CHILD HAS BEEN IMMUNIZED AGAINST DIPHTHERIA, PERTUSSIS, TETANUS, MEASLES, MUMPS, RUBELLA, POLIO, HEPATITIS B, AND CHICKEN POX. IN ADDITION A LEAD SCREENING MUST HAVE BEEN PERFORMED. A DENTAL EXAMINATION SHOULD ALSO HAVE BEEN PERFORMED.

PHYSICIAN __________________________________________ PHONE NUMBER ____________________________________

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, WITHIN TWO WEEKS. THIS STATEMENT SHALL VERIFY THAT THE FOLLOWING LIMITATIONS ARE NECESSARY:

____________________________________________________________________________________________________________

SIGNATURE _____________________________________________________ RELATIONSHIP __________________________

DATE __________________________________________________