REGISTRATION FORM

01/00

PORTSMOUTH SCHOOL DEPARTMENT

PORTSMOUTH, RHODE ISLAND

 

 

                                                                                                                                                                                                SEX

STUDENT'S NAME _____________________________________________     DATE OF BIRTH _______________ M ___ F ___

 

 

ADDRESS _____________________________________________________     BIRTHPLACE _____________________________

 

                  ____________________________________________________      TELEPHONE NUMBER _____________________

                                                                                                                                                   UNLISTED NO. KEPT CONFIDENTIAL

STUDENT'S SOCIAL SECURITY # __________________________________ (OPTIONAL)

 

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

 

BROTHERS/SISTERS -

 

__________________________		_____________________		_________________________		__________________
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 ____________________________________________________ DATES  ATTENDED __________________________

                                        (INCLUDE CITY/STATE/ZIP)

 

GRADE ENTERING ______________ IF HELD BACK, NOTE GRADE AND YEAR _______________________________ ____ _

 

PLEASE CHECK BELOW ANY AREA IN WHICH YOUR 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 LIVES.

 

MOTHER _____________________________________________ FATHER ______________________________________________

 

PARENT  _______         STEP PARENT _________                                PARENT  _______         STEP PARENT _________

 

OCCUPATION _________________________________________ OCCUPATION _________________________________________

 

EMPLOYER ___________________________________________ EMPLOYER __________________________________________

 

EMPLOYER'S                                                                                     EMPLOYER'S

ADDRESS _____________________________________________ ADDRESS ____________________________________________

 

EMPLOYER'S TELEPHONE ______________________________ EMPLOYER'S TELEPHONE ____________________________

 

 

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 JURIS-

                                                                                                            DICTION?

ADDRESS ____________________________________________                        YES ___       NO ___

 

OCCUPATION ________________________________________   IF NO, PLEASE PROVIDE THE SCHOOL WITH DOCUMENTED 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			PHYSICAL HANDICAP
EMOTIONAL PROBLEMS			HEART CONDITIONS			ADD/ADDH

 

IF YOU ANSWER 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 HICLD 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 CASE OF ILLNESS OR INJURY.)

 

NAME ____________________________________________________                                                                PHONE NUMBER ______________________________________

ADDRESS _________________________________________________                                                                 RELATIONSHIP TO CHILD ______________________________

 

 

IMMUNIZATIONS.   RHODE ISLAND STATE LAW REQUIRES THAT ALL STUDENTS ENTERING ANY PUBLIC OR PRIVATE 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.  A DENTAL EXAMINATION SHOULD ALSO HAVE BEEN PERFORMED. 

 

PHYSICIAN _______________________________________________                                                                 TELEPHONE NUMBER _________________________________

 

DENTIST _________________________________________________                                                                 TELEPHONE 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 ______________________