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Jordan-Elbridge Central School District Student Registration

Last*

First*

Middle

Grade:

Age:

Date of Birth:*

Male Female Unidentified

Gender:

Birthplace:

Home Phone:

Yes No

No Yes

Please provide date(s)/grade(s):

Transferring from District/School Name & Address:

List any other school districts the student has been enrolled at:

Has student previously received services?

English as a Second Language Speech Language Special Education 504 OT PT

Preschooler with a disability

Reading Support (AIS)

Counseling

Math Support (AIS)

Other

Specify:

Student resides with:

Sole Custody Joint Custody Court Protection Order in Effect

Relationship to Student:

Mother

Step-Parent

Other:

Father

Legal Guardian

Name:

Education:

Email:

Employer:

Employer Phone:

Cell Phone

Relationship to Student:

Mother

Step-Parent

Other:

Father

Legal Guardian

Name:

Education:

Email:

Employer:

Employer Phone:

Cell Phone:

Jordan-Elbridge Central School District Student Registration

Contact information regarding parent not residing with student (divorced or separated parents):

Relationship to Student:

Yes No

Home Phone:

Address:

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at time of registration along with the following information:

Name of Case Worker (if applicable):

Phone:

Years

Months

Yes No

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Yes No

Please select one or more races from the following racial groups that apply to your child (must select at least one):

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Siblings residing with student at same address:

(Please list ALL children residing in home.)

A Name	B Gender	C Date of Birth	D Grade

Parent/ Legal Guardian Signature (use mouse)

Date*

STUDENT RESIDENCY QUESTIONNAIRE

Name of Student:

Last

First

Middle

Birth Date:

Age:

School:

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C 11435. The answers to this residency information help determine the services the student may be able to receive.

1. Is your current address a temporary living arrangement? *

Yes No

2. Is this temporary living arrangement due to the loss of housing or economic hardship?

Yes No

You answered YES to one of the questions above. Please fill out the remainder of the form.

Where is the student presently living?

Hotel / Motel

In a Shelter

Moving from place to place

With another family or other person because of loss of housing or as a result of economic hardship (referred to as 'doubled-up')

In a place not designated for ordinary sleeping accommodations such as a car, park or campsite

_____________________________________________________________________________

Print Name of Parent or Legal Guardian

Street Address

Phone

City, State, Zip

Note: Presenting a false record or falsifying records is an offense under Section 37.10, Penal Code, and enrollment of the child under false documents subjects the person to liability for tuition and other costs.

Signature of Parent or Legal Guardian (use mouse to sign)

Date

Complete Legal Name of Student

Has your Child ever attended Jordan-Elbridge Schools in the past?

Parent / Legal Guardian information (residing with student)

Can they be called for emergencies by the district?

Is your child Hispanic, Latino, or of Spanish Origin?

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If YES, please check services received below:

Physical Address:*

Mailing Address:*

Cell Phone:

Parent's Name:

Email Address:

Foster Care Placement Must Provide

Form DSS-2999

Placement is considered to last for what period of time?

School Phone:

Yes No

*

Before submitting this form, please check your answers. Any questions with a red * are required. After submitting the form if you get a validation error, please look for and complete any questions/fields that turn red.

*

Is this the primary contact number?

If parents do not reside in same household, please identify arrangement. I have:

Court papers must be on file with the Jordan-Elbridge Central School District giving specific instructions regarding custody of student and access to records Complete information on both parents is required if joint custody exists:

Is the Student considered Neglected/Delinquent?

(Hispanic, Latino or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race)

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HOME LANGUAGE QUESTIONNAIRE

In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English

In what language(s) would you like to receive information from the school?

English Other

What is the Home Language of each parent/guardian?

What was the first language your child learned?

What language(s) does your child understand?

What language(s) does your child speak?

What language(s) does your child read?

What language(s) does your child write?

English Other

Mother

Father

Guardian

Not Applicable English Other

English Other

Language Background (Please check all that apply.)

Educational History

Indicate the total number of years that your child has been enrolled in school:

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?

Yes No Not sure

You answered Yes or Not sure ...Please explain below:

Minor Somewhat severe Very severe

How severe do you think these difficulties are?

No Yes

Has your child ever been referred for a special education evaluation in the past?

You indicated your child has been referred in the past, has your child ever received any special education services in the past?

No Yes

What services?

Age at which services received (Please check all that apply):

Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)

No Yes

Does your child have an Individualized Education Program (IEP)?

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Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

OFFICIAL ENTRY ONLY

HLQ Administrator name:

Position:

HLQ Reviewer/Interviewer name:

Position:

No Yes

Oral Interview necessary?:

Date:

Outcome:

NYSITELL Administrator Name:

Position:

NYSITELL Date:

Proficiency Level Achieved on NYSITELL:

For students with disabilities, list accomodations administered in accordance with IEP pursuant to CSE recommendation:

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years

You indicated yes click here to complete Medicaid Consent