File Name: JPS Registraon Form r6-2020 (EN) Johnston Public Schools Student Registration Form REGISTRATION DATE: / / TIME : : AM/PM DATE: / / GRADE: THIS SECTION FOR OFFICE USE ONLY IDENTIFICATION IDENTIFICATION Birth Cerficate (Original) Passport DCYF Intrastate ID Card (also serves as proof of residency) IMMUNIZATIONS IMMUNIZATIONS Checked by: Checked on: / / [ ] Complete [ ] DCYF PROOF PROOF OF OF RESIDENCY RESIDENCY [ ] Purchase and sales agreement [ ] Property tax bill (in name) [ ] Current ulity bill : gas /electric / landline telephone bill) [ ] Residency Affidavit [ ] Bank Closing Selement Sheet [ ] DCYF Intrastate ID Card) PLACEMENT PLACEMENT Special Ed placement [ ] IEP [ ] 504 Out-of-district [ ] ELL (check if required) Confirmed with SCHOOL SCHOOL [ ] Graniteville (PK) AM/PM 16110 [ ] Early Childhood Center (K) 16114 [ ] Sarah Dyer Barnes Elementary (K-5) 16108 [ ] Brown Avenue Elementary (1-5) 16106 [ ] Winsor Hill Elementary (1-5) 16109 [ ] Thornton Elementary (1-5) 16103 [ ] Nicholas A Ferri Middle School (6-8) 16111 [ ] Johnston High School (9-12) 16112 [ ] Other ______________________________ Student Details Student Name: _______________________________________________________________________________ Grade: (Legal Last Name/s) (First Name) (Middle Name) Home Address: _________________________________________________________________________________________________ (House Number) (Street Name) (Apt./Unit #) (City) (State) (Zip) Gender: □ Female □ male Date of Birth: Country of Birth: _____________________ STEP 1: Student Information LASID # Local Student ID PLEASE PRINT and COMPLETE EACH SECTION Student History Indicate date first enrolled in ANY U.S. school. ___________________________ (Month / Day /Year) School last aended: (School Name) (Location) (Phone number) Has your child ever been enrolled in the Johnston Public Schools? Yes No Student Ethnicity and Race New Federal standards require that school districts collect and report information regarding race and ethnicity . What is your child’s race? American Indian/Alaskan Nave Black/African American Nave Hawaiian/Other Pacific Islander White Asian If your child is Southeast Asian, please indicate their country of origin or ethnic group. Brunei Burma (Myanmar) Cambodia Philippines Hmong Indonesia Laos Malaysia Thailand Timor-Leste Singapore Vietnam Is your child Hispanic or Lano? Yes No I certify that the information I have provided in this document is accurate, and that the child named above will be per- manently residing at the indicated address. It is my responsibility to notify the school of any change of information. Parent/Legal Guardian Signature: Date: Specialized Services Section Does your child presently have an Individualized Educaon Plan (IEP)? Yes No Are you providing a copy of your child’s IEP? Yes No Has your child had a screening test with Child Outreach? Yes No Does your child have a Secon 504 Plan? Yes No Does your child presently receive any English Language Learner (ELL) instrucon? Yes No Does your child receive any other services not already menoned? If yes, please explain: Yes No HOME LANGUAGE SURVEY Signature acquired from person [ ] Giving HLS [ ] Reviewing & Interviewing [ ] Giving Language Assessment [ ] Reporting Scores
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Student Registration Form - Johnston Public Schools
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Gender: □ Female □ male Date of Birth: Country of Birth: _____________________
STEP 1: Student Information LASID # Local Student ID
PLEASE PRINT and COMPLETE EACH SECTION
Student History
Indicate date first enrolled in ANY U.S. school. ___________________________ (Month / Day /Year)
School last attended: (School Name) (Location) (Phone number)
Has your child ever been enrolled in the Johnston Public Schools? Yes No
Student Ethnicity and Race
New Federal standards require that school districts collect and report information regarding race and ethnicity .
What is your child’s race?
American Indian/Alaskan Native Black/African American Native Hawaiian/Other Pacific Islander White Asian
If your child is Southeast Asian, please indicate their country of origin or ethnic group. Brunei Burma (Myanmar)
Cambodia Philippines Hmong Indonesia Laos Malaysia Thailand Timor-Leste Singapore Vietnam
Is your child Hispanic or Latino? Yes No
I certify that the information I have provided in this document is accurate, and that the child named above will be per-
manently residing at the indicated address. It is my responsibility to notify the school of any change of information.
Parent/Legal Guardian Signature: Date:
Specialized Services Section
Does your child presently have an Individualized Education Plan (IEP)? Yes No
Are you providing a copy of your child’s IEP? Yes No
Has your child had a screening test with Child Outreach? Yes No
Does your child have a Section 504 Plan? Yes No
Does your child presently receive any English Language Learner (ELL) instruction? Yes No
Does your child receive any other services not already mentioned? If yes, please explain: Yes No
HOME LANGUAGE SURVEY
Signature acquired from person
[ ] Giving HLS
[ ] Reviewing & Interviewing
[ ] Giving Language Assessment
[ ] Reporting Scores
File Name: JPS Registration Form r6-2020 (EN)
Custody Arrangement (CIRCLE ONE): SOLESOLE DUALDUAL N/AN/A If living with foster parents, agency name:
1) Parent/Guardian FatherFather MotherMother Has legal custody Yes No Name
Address: Cell Phone: (If different from student)
Email Address: Work Phone:
Language spoken at home: Home Phone:
2) Parent/Guardian FatherFather MotherMother Has legal custody Yes No Name
Address: Cell Phone: (If different from student)
Email Address: Work Phone:
Language spoken at home: Home Phone:
Do you have other children attending Johnston Public Schools? Yes No If yes, please list name and grade below.
Emergency Contacts and Release Procedures
In the event of a major illness or injury, 9-1-1 will be called first. If you are unavailable, we will contact the individuals below in the order listed in the event of an illness or emergency involving your child. The people listed should be available during school hours. Your child may also be released to these individuals under other circumstances at your request or the school’s request. Suitable identification (e.g., driver’s license) will be necessary before the child is released. These are the only people authorized to pick up your child from school. Please complete this section as accurately as possible.
I, authorize the school to release my child to the individuals named below: PARENT / GUARDIAN NAME (PLEASE PRINT)
Name Relationship Daytime Phone (Please indicate home, work or cell)
1.) (H) (W) (C)
2.) (H) (W) (C)
3.) (H) (W) (C)
Permission to photograph/videotape your child
We are proud of our students and the events that take place at our schools. Occasionally throughout the year, we invite the press to report on our events. If we have permission to photograph your child, you DO NOT need to do anything. CHECK THE BOX BELOW IF YOU DO NOT GIVE PERMISSION FOR YOUR CHILD TO BE PHOTOGRAPHED, VIDEO-
TAPED AND/OR ON THE DISTRICT WEB SITE.
I do not consent for my child to be photographed or videotaped at school events or published in media or on school websites.
Parent/ Guardian Signature: Date:
Page 2 of 9 Student Registration Form—Continued
Student Name: Date of Birth: Grade:
Johnston Public Schools
STEP 2: Family Information LASID # Local Student ID
PLEASE PRINT and COMPLETE EACH SECTION
File Name: JPS Registration Form r6-2020 (EN)
Page 3 of 9 Student Registration Form—Continued
Health History Form
Johnston Public Schools
STUDENT NAME: (PLEASE PRINT) □ male □ Female DATE OF BIRTH:
Last Name First Name MI
/ / Month Day Year
Home Address:
Street Name City State Zip
Parent/Guardian Information: (PLEASE PRINT)
Name
Home Number
Work Number
Cell Number
Street Address (If different from Student) City State Zip
Name
Home Number
Work Number
Cell Number
Street Address (If different from Student) City State Zip
Health Care Provider: (PLEASE PRINT)
Name
Telephone Number
Street Address (If different from Student) City State Zip
MEDICAL HISTORY (Please check one response for each of the following diseases or conditions)
File Name: JPS Registration Form r6-2020 (EN)
Page 4 of 9 Student Registration Form—Continued
Student Name: Date of Birth: Grade:
Johnston Public Schools
Health History Information (Continued)
MEDICATIONS
Is the student currently taking any medications? Yes No
If yes, please provide the name of the medication(s) below:
1. Dosage: Number of times daily?
Prescribing physician: Reason for the medication:
2. Dosage: Number of times daily?
Prescribing physician: Reason for the medication:
3. Dosage: Number of times daily?
Prescribing physician: Reason for the medication:
IN THE SPACE BELOW, PLEASE PROVIDE ANY ADDITIONAL HEALTH INFORMATION, WHICH YOU FEEL WOULD BE HELPFUL TO THE SCHOOL NURSE-TEACHER:
What school did your child last attend?
City/Town State Telephone Number
I UNDERSTAND THIS INFORMATION MAY BE SHARED AND DISCUSSED WITH SCHOOL PERSONNEL IF NECESSARY. I GIVE PERMISSION TO APPROPRIATE SCHOOL PERSONNEL TO COMMUNICATE AND EXCHANGE INFORMATION WITH THE STUDENT’S PHYSICIAN, IF NECESSARY.
SIGNATURE PARENT/GUARDIAN DATE
Does your child have asthma? Yes No If Yes, list the triggers:
Medications prescribed: Medication required during school day? Yes No
Time of year asthmatic episodes most often occur:
Does your child have diabetes? Yes No If Yes, age of diagnosis: Type 1 or Type 2
Insulin dependent: Yes No If Yes, pump or injection:
Does your child have any vision defects? Yes No If Yes, please specify:
your child wear contacts? Yes No Glasses? Yes No Is it necessary for your child to sit near board? Yes No
Does your child have any hearing defects? Yes No If Yes, please specify:
your child wear hearing aids? Yes No Use an FM device? Yes No
Is it necessary for your child to sit near front of room? Yes No If Yes, please circle which side of the room they would prefer? Left Right
The R.I. Board of Education does not discriminate on the basis of age, sex, sexual orientation, gender identity/expression, race, color, religion, national origin, or disability.
File Name: EN HomeLangSurvey-JPS-new-final-7-01-2020 Page 5 of 9
Home Language Survey (HLS) To be completed by Parent or Guardian
Dear Parent or Guardian,
The information requested on this
form is necessary for the most
appropriate school placement of
your child, and will not be used for
any other purposes1.
Thank you for your collaboration.
Student Name:
First Middle Last
Date of Birth: Place of Birth2:
_______________________________ ________________________________ Month Day Year
Parent or Guardian Relationship to Student:
Mother Father Other _______________________________
Home Language Code:
Language Background (Please check all that apply)
1. What is the primary language used in the home, regardless of the language spoken by the student?
English Other _________________________________________ Specify
2. What is the language most often spoken by the student?
English Other _________________________________________ Specify
3. What is the language that the student first acquired?
English Other _________________________________________ Specify
4. What language(s) does your child understand?
English Other _________________________________________ Specify
5. What language(s) does your child speak? English Other ____________________________ Specify
Does not speak
6. What language(s) does your child read? English Other ____________________________ Specify
Does not read
7. What language(s) does your child write? English Other ____________________________ Specify
Does not write
1 Required by Rhode Island Law (R.I.G.L. 16-54-2) and the Equal Opportunity Education Act (20 U.S.C. 1703(f)) 2 Families are not required to provide the place of birth, but providing the information can help LEAs to better prepare to be culturally responsive. Last Updated 4/30/2020
The R.I. Board of Education does not discriminate on the basis of age, sex, sexual orientation, gender identity/expression, race, color, religion, national origin, or disability.
Page 6 of 9
Family Interview – Educational History 1. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write
in English or any other language? If yes, please describe them.
Yes No
Not Sure *If yes, please explain: ______________________________________________________
2a. Has your child ever been referred for a special education evaluation in the past? No Yes*
* If referred for an evaluation, has your child been identified? No Yes*
* If referred for an evaluation, and identified has your child ever received any special education services in the past?
No Yes – Type of services received: _______________________________________________________________________
2b. Age at which services received (Please check all the apply)
Birth to 3 years (Early Intervention)3 to 5 years (Special Education) 6 years or older (Special Education)
2c. Does your child have an Individualized Education Program (IEP), or a 504 plan? No Yes
3. In which language do you prefer to receive oral communications from the school or district? English Other _______________________________________
Specify
4. In which language do you prefer to receive written communications from the school or district? English Other _______________________________________
Specify
5. Indicate date first enrolled in any US. School ________________________________________________________________ (mm/dd/yyyy)
Is there anything else that you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS: _________________________________________________ NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLS AND CONDUCTING INDIVIDUAL INTERVIEW
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS: _________________________________________________ NAME/POSITION OF QUALIFIED PERSONNEL REPORTING THE LANGUAGE SCREENING SCORES
I own and reside at the residence located at the address listed above.
I rent or otherwise reside at all or a portion of the residence located at the address listed
above, but I am not the owner. (3) I have enclosed copies of the following documents as proof of residence for the child(ren) listed above:
(Please provide at least three (3) documents from the following list. Monthly bills must be
dated within the previous thirty (30) days)
Copy of deed and most recent mortgage payment Bank Statement Copy of lease agreement and proof of most recent rental payment Current Payroll Stub Section 8 Agreement Current Vehicle Registration Recent Insurance bill/policy Credit Card Statement W-2 Tax return for previous year Electric, cable, gas or water bill Current property or motor vehicle tax bill Current proof of SNAP/SSI Benefits
ACKNOWLEDGEMENT
I certify that the above information is true and correct. I understand that this information will be verified by
the Registrar, and if found to be fraudulent, I understand that the falsification of any information on this
form may result in me being liable to the Town of Johnston for the reimbursement of any expenses
incurred by the Town in educating the listed child(ren) and/or being subject to criminal prosecution
resulting from any fraud or negligent misrepresentation contained on this form. I acknowledge that as
Parent/Guardian, I must immediately notify the Johnston Public Schools of any change in residency and
I certify that the above information is true and correct. I understand that the Registrar for the Johnston Public Schools will verify by homeownership status with the Registry of Deeds and the Tax Assessor for the Town of Johnston, and if the information I have given is found to be fraudulent, I understand that the falsification of any information on this form may result in me being liable to the Town of Johnston for the reimbursement of any expenses incurred by the Town in educating the listed child(ren), and/or being subject to criminal prosecution resulting from any fraud or negligent misrepresentation contained on this form.
Subscribed and sworn to before me on this __________day of _____________, 20____.
______________________________________ (Notary Public) My commission expires: _________________
Revised 7-10
STATE OF RHODE ISLAND
School Name & Address:
Health Care Provider Name and Address: Phone:
SCHOOL PHYSICAL FORM
This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4) Student Name: Last First Middle Date of Birth
Sex
Address: Street Apt # City State Zip Code Home Phone
PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript). IMMUNIZATIONS Please enter dates in MM/DD/YYYY format
Hepatitis B
Diphtheria-Tetanus-Pertussis DTP/DTaP
Check if DT
Check if DT
Check if DT
Check if DT
Check if DT Pneumococcal Conjugate
PCV
Polio
Haemophilus Influenzae Type B Hib
Measles-Mumps-Rubella MMR
Varicella
Student has history of varicella disease
Tetanus-Diphtheria-Pertussis TdaP/Td
Check if Td
Check if Td
Check if Td
Rotavirus
Hepatitis A
Meningococcal
HPV
Immuni
zation Exemption: Medical Religious
Hep B DTaP PCV Polio Hib MMR Varicella Td/Tdap Rotavirus Hep A Mening HPV PHYSICAL EXAMINATION
Date of PE _____/_____/_____ Height ___________ Weight___________ BP____________ Please note any health problem, chronic health condition or disability that may affect behavior or health at school:
ASTHMA: No Yes DIABETES: No Yes OTHER: ___________________________________________________________________
Significant Systems Findings: __________________________________________________________________________________________________________________
ALLERGIES: No Yes (Please explain) ___________________________________________EPINEPHRINE AUTO-INJECTOR REQUIRED: No Yes Treatment Plan: ____________________________________________________________________________________________________________________________ MEDICATION (REQUIRED AT SCHOOL): No Yes (Please list) _______________________________________________________________________ Other medication(s) that may affect behavior or health at school: _____________________________________________________________________________________ RESTRICTIONS: Can participate in physical education: Fully With limitation _____________________________________________________
Can participate in sports: Fully With limitation _____________________________________________________
LEAD SCREENING (Required for children < 6 years of age only) Student is in compliance with lead screening requirements:
Yes No
SCOLIOSIS SCREENING Yes No
VISION SCREENING (Children entering Kindergarten) Passed screening Screened and referred for comprehensive exam Referred for comprehensive exam, but not screened
TUBERCULOSIS (If required by school district) Date of TB test:
Screening Date: Comprehensive Exam Date:
HEALTH CARE PROVIDER SIGNATURE: ________________________________________________________________ DATE: _________________________________