Lawrence Public Schools Student Registration Form

Child’s Name:

Date:

(Last Name)

(First Name)

(Middle Name)

Address: Phone: (Zip Code) (Number)

D.O.B:

/

(Street)

/

(Unit/Floor)

Place Of Birth: (City)

Is the Student Hispanic:

Yes or No



Ethnic Group:

(State or Country)

Gender:

M/F

(Example: Dominican, Puerto Rican, Guatemalan, Ecuadorian, Portugese, Vietnamese, Cambodian, Lebanese, Etc.)

Black or

American Indian or

Native Hawaiian or

Race: (Circle all that apply) White Asian African American Alaskan Native Other Pacific Islander Language Spoken at Home: Guardian 1

Date of entry into US: Guardian 2

Relationship:

Relationship:

Name:

Name:

Address:

Address:

Home Phone:

Home Phone:

Cell Phone:

Cell Phone:

Email:

Email:

Employer:

Employer:

Occupation:

Occupation:

Work Phone:

Work Phone:

Place of Birth:

Place of Birth:

Child Lives With:(Circle all that apply) Guardian 1 Guardian 2 Both Has this child previously been enrolled with the Lawrence Public Schools? Yes No If so, what school(s) School Grades PK K 1 2 3 4 5 6 7 8 9 10 11 12 13 School Grades PK K 1 2 3 4 5 6 7 8 9 10 11 12 13 School Grades PK K 1 2 3 4 5 6 7 8 9 10 11 12 13 I Understand that I need to complete the enrollment process including the provision of all required information and that the information I have provided is true. Parent/Guardian Signature: STAFF ONLY Holding School: Grade: Program Code: ID# School Assignment: Effective Date:

Entered into Computer by:

Immunizations: 1

Student Last Name, First Name

Lawrence Public Schools Student Information Form

LASID DOB

Does the student meet any of the following criteria regarding household member’s military status? 1. 2. 3.

A student enrolled in K-12 in the household of a full-time duty status in the active uniformed service of the United States, including members of the National Guard and Reserve on active duty orders pursuant to 10 U.S.C. Section 1209 and 1211. Members or veterans of the uniformed services who are severely injured and medically discharged or retired for a period of one year. Members of the uniformed services who died on active duty or as a result of injuries sustained on active duty for a period of one year after death. Yes No Is the student considered any of the following?(Please circle all that apply)

Migrant Refugee Immigrant Foster Child Ward of the State Homeless

Yes Yes Yes Yes Yes Yes

No No No No No No

Brothers and Sisters

(If more space is needed please list them on a separate sheet)

Name:

DOB:

School:

Name:

DOB:

School:

Name:

DOB:

School:

Name:

DOB:

School:

Name:

DOB: Previous School Experience

School:

(If more space is needed please list them on a separate sheet)

Day Care/Preschool

Country/City/School

1. 2. 3. 4. 5.

Age

Language of Instruction

Elementary, Middle School, and/or High School Experience Country/City/School Grade Retention Language of Instruction From To Gr. From To Gr. From To Gr. From To Gr. From To Gr.

Parent/Guardian Signature: 2

Student Last Name, First Name

Lawrence Public Schools Home Language Survey

LASID DOB

Date:

1a. What is the native language of mother/guardian 1? (check one) English

Spanish

Vietnamese

Khmer

Other

1b. What is the native language of father/guardian 2? (check one) English

Spanish

Vietnamese

Khmer

Other

2. What language did your child first understand and speak? (check one) English

Spanish

Vietnamese

Khmer

Other

3. Which other languages does your child know? (circle all that apply) English

Speak Read Write

Speak Read Write

Spanish

Vietnamese

Speak Read Write

Khmer

Speak Read Write

Other

Speak Read Write

4. Which language do you use most with your child? (check one) English

Spanish

Vietnamese

Khmer

Other

5. Which languages does your child use? (circle all that apply) English

Seldom Sometimes Often Always

Spanish

Seldom Sometimes Often Always

Vietnamese

Seldom Sometimes Often Always

Khmer

Seldom Sometimes Often Always

Other

Seldom Sometimes Often Always

6. Which language(s) are spoken with your child?(include relatives - grandparents, uncles, aunts, caregivers, etc.) (circle all that apply) English

Seldom Sometimes Often Always

Spanish

Seldom Sometimes Often Always

Vietnamese

Seldom Sometimes Often Always

Khmer

Seldom Sometimes Often Always

Other

Seldom Sometimes Often Always

7. Will you require written information from school in your native language? YES

NO

8. Will you require an interpreter/translator at Parent-Teacher meetings? YES

NO

Parent/Guardian Signature: Intake Person Dept/School Information must be recorded by a school department employee and a copy of this form must be sent to The Community, Family, and Student Engagement Department. 3

Student Last Name, First Name

Lawrence Public Schools Emergency Procedure Child’s Name: Last:

First:

LASID DOB

Middle:

Address: In case of emergency, illness or accident to the above named student, a school representative is authorized to contact: Guardian 1 Name:

Daytime Phone:

Place of Employment: Occupation/Title/Department: Guardian 2 Name:

Daytime Phone:

Place of Employment: Occupation/Title/Department: Please Name 2 other people who can assume responsibility for the child in the event that neither guardian can be contacted. Emergency Contact #1 Name:

Relationship:

Address:

Phone:

Emergency Contact #2 Name:

Relationship:

Address:

Phone:

If any of the above information changes please contact your child’s school immediately!

Parent/Guardian Signature: Date:

4

Student Last Name, First Name

Lawrence Public Schools Student Health Questionaire Physician’s Name: Physician’s Address: Telephone: Health Insurance:(Yes/No)

LASID DOB

Dentist’s Name: Dentist’s Address: Telephone: Name of Insurance:

Policy#:

1. When did your child last see a medical doctor and why? 2. When did your child last see a dentist and why? 3. Does/ Has your child have/had disease(s) that affects the function of the eye, ear, heart,kidney, muscles, lungs, or immune system:

Yes

No

If Yes Please Explain 4. List any operations, fractures, sprains, or bone dislocations 5. Please indicate the age at which your child accomplished the following: Sitting

Walking

Simple Words

Toilet Training

Dressing Self

Feeding Self

Sentences

6. Has your child ever had any of the following? Please circle Y for Yes and N for No. a.

Allergies(food, insects, drugs, latex)

Y

N

m.

Diabetes

Y

N

b.

Allergies(seasonal)

Y

N

n.

Head or Spine Injury

Y

N

c.

Asthma or Breathing Problems

Y

N

o.

Hearing problems or deafness

Y

N

d.

Attention Deficit/Hyperactivity disorder

Y

N

p.

Heart Problems

Y

N

e.

Behavorial Problems

Y

N

q.

Hospitalizations

Y

N

f.

Developmental Problems

Y

N

r.

Lead Poisoning

Y

N

g.

Bladder Problems

Y

N

s.

Muscle Problems

Y

N

h.

Bleeding Problems

Y

N

t.

Seizures

Y

N

i.

Bowel Problems

Y

N

u.

Sickle Cell Disease(not trait)

Y

N

j.

Cerebral Palsy

Y

N

v.

Speech Problems

Y

N

k.

Cystic Fibrosis

Y

N

w.

Surgery

Y

N

l.

Dental Problems

Y

N

x.

Vision Problems

Y

N

Y

N

Does your child have any psychological or mental health problems ? Please explain any of the “Yes” answers to the above questions: Please list allergies: Epipen Prescribed? Yes No 7. Describe any other important health related information about your child(IE: feeding tube, oxygen support, etc) 8. Has your child ever had chicken pox? Yes 9. List all prescriptions your child takes: 10. Does your child wear glasses? 11. Is your child able to participate in the school’s regular program of physical activities? If “No” Please Explain

No

When?

Yes Yes

No No

Parent/Guardian Signature: Date: 5

Lawrence Public Schools Authorization for Exhange of Health and Education Information Patient/Student Name Date of Birth I hereby Authorize (health care provider and name) and (name and title of school official) to exchange health and education information/records for the purpose listed below. (address & telephone of school/school district) (address & telephone number of healthcare provider)

Description: The health information to be disclosed consists of: The education information to be disclosed consists of: Purpose: This information will be used for the following purpose(s): 1. Educational evaluation and program planning 2. Health assessment and planning for health care services and treatment in school 3. Medical evaluation and treatment 4. Other:

Authorization This authorization is valid for one calendar year. It will expire on (date). I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records, once recieved by the school district, may not be protected by the HIPPAA Privacy Rule, but will become education records protected by the Family Educational Rights to Privacy Act. I also understand that if I refuse to sign, such refusal will not interfere with my child’s ability to obtain health care. Parent/Guardian Signature

Date

Student Signature*

Date

*If a minor student is authorized to consent to healthcare without parental consent under federal or state law, only the student shall sign the authorization form. A competent minor depending in age can consent to outpatient mental health care, alcohol and drug abuse treatment, testing for HIV/AIDS, and reproductive health care services. Copies: Parent or Student* Physician or other healthcare provider releasing protected health information School official requesting/receiving the protected information

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Lawrence Public Schools Authorization for Release of Student Records The following is in accordance with the provisions of Public Law 93-380 and Massachusetts Law H R 16900 I, as the parent/guardian, or a student 18 years or older, hereby authorize the transfer of school records as indicated upon receipt of this request. from the School

Address

School

Address

to the

City/Town

Student’s Name (print)

Parent’s Name (print)

Address

Parent’s Signature

State

DOB

Scholastic Records Health Records Attendance Records Other(please specifiy):

Zip

Date of Request

Address

City/Town

State

ZIP

Standardized Test Scores Psychological/Medical Report Family Background Data Please Check all that Apply

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