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District Registration Form

LaFayette Central School District

5955 U.S. Route 20 West LaFayette, NY 13084

Telephone: 315-677-9728 Fax: 315-677-3372

www.lafayetteschools.org

STUDENT INFORMATION

Please complete all the information requested and check the appropriate spaces.

Last Name

First Name

Middle Name

Street Address

City

Zip

Gender:

Residence Phone Number:

Home Language

REGISTRATION INFORMATION

For School-Age Children Only

Previous School Attended and Address:

Phone Number:

School Entering

Entering into Grade

Transportation By

Has student ever attended LaFayette CSD ?

Yes No

What years?

Has student ever received Special Education or Section 504 Services? *

Yes No

Is student currently classified?

Yes No

Was the student held out an extra year before entering Kindergarten?

Yes No

Has the student been held back an extra year?

Yes No

What grade?

Is the student receiving Academic Intervention/Support Services?

Yes No

Speech Occupational/Physical Therapy Reading AIS Adaptive PE

What services?

FAMILY BACKGROUND

Student lives with:

Relationship

Do you have legal documentation of custody?

Parent/Guardian deceased?

Yes No

Name of deceased:

Both Parents Father Mother Other

CUSTODIAL PARENT/GUARDIAN INFORMATION:

Primary Contact/Guardian

Last Name

First Name

Relationship

Street Address

City

Zip

Home Telephone

Cell

Yes No

SMS Texting?

Employer

Work Telephone/extension

Secondary Contact/Guardian

Last name

First Name

Relationship

Street Address

City

Zip

Home Telephone

Cell

Yes No

SMS Texting?

Employer

Work Telephone/extension

First & Last Name

Age

Sex

Birthdate

School (if applicable)

M F

Name 1

Relationship

Address

Telephone

Cell Home

OTHER CHILDREN IN THE HOME:

EMERGENCY CONTACTS: List up to four (4) local emergency contacts who are available during school hours.

Name 2

Relationship

Address

Telephone

Cell Home

Name 3

Relationship

Address

Telephone

Cell Home

Name 4

Relationship

Address

Telephone

Cell Home

McKinney-Vento Registration Form

School Year:

Last*

First*

Student Name:

Middle

Date of Birth:*

Age:

Female Male

Gender:

The answers to these residency questions and the information given will help us to determine the services that the student may be eligible to receive.

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

Yes No

2) If yes, is this temporary arrangement due to loss of housing or economic hardship ?

Yes No

3) Is this temporary arrangement voluntary ?

Yes No

You answered YES to questions 1 AND 2, please complete the remainder of this form.

You answered No to question 1 or question 2, you may stop here and scroll down to the next section.

in a motel

in a shelter

with more than one family in a house or apartment

moving from place to place

in a car or campsite

other

explain

a parent/guardian friends or family members by himself/herself a head of household

The student lives with

Where is the student presently living?*

Parent Legal Guardian Head of Household

Name of

Address:

City:

ST:

Zip:

STUDENT INFORMATION

HOUSING

ACKNOWLEDGEMENT

Home Telephone:

Work Telephone:

Cell Phone:

I am the parent/legal guardian/head of household of

who is seeking admission to the LaFayette Central School District.

Since

our family has been living under the above mentioned temporary living arrangements.

We anticipate moving into a permanent residence by

we do not yet know when we will obtain permanent residency.

I declare under penalty of perjury under the laws of New York State that the information provided here is true and correct.

Date*

The District reserves the right to verify any and all information contained in the above form.

Parent/Guardian Signature

Female Male

ETHNICITY

(please check all that apply)

Hawaiian/Other Pacific Islander American Indian or Alaskan Native

Yes No

Living on Reservation?

Name of School:*

Grade:*

TRANSPORTATION

Yes No

Will this student be utilizing LaFayette School District Transportation (if available)?*

LaFayette Central School District

ACKNOWLEDGEMENT

Date:*

Parent/Guardian Signature

Parent/Guardian Name:

Relationship:

According to the Final Regulations - Family Education Rights and Privacy Act (Buckley Amendment) dated June 17, 1976, it is no longer necessary to obtain written consent to release records between schools. It states that school officials, including teachers within an educational institution and officials of other schools in school systems in which the student may intend to enroll, may receive a student's record without a written consent for such a release.

Student Name:

Date of Birth:

Grade:

Previous School District:

School Name:

Previous School Phone:

Previous School Fax:

Release of Information Form

LaFayette Central School District

5955 U.S. Route 20 West LaFayette, NY 13084

Telephone: 315-677-9728 Fax: 315-677-3372

www.lafayetteschools.org

5955 U.S. Route 20 West LaFayette, NY 13084

Telephone: 315-677-9728 Fax: 315-677-3372

STUDENT INFORMATION

Last

First

Middle

Please send the following information to the appropriate department(s) below so that a proper placement can be made on

* Transcript/Report Cards

* Guidance/Anecdotal Records

* Attendance Reports

* Psychological Evaluation

* Standardized Test Scores/Regents Assessments

* Academic Intervention Service Records

* Health Records (including Immunizations)

* Discipline Records

* IEP/CSE Records

* Birth Certificate

Central Registration

Attn: Paula Hibbert

Fax: 315-677-3372

phibbert@lafayetteschools.org

(Any Iep/CSE Paperwork)

Dept of Pupil Services

Attn: Patricia McElhannon

Fax: 315-677-3372

pmcelhannon@lafayetteschools.org

ACKNOWLEGEMENT

Parent/Guardian Signature:

Date:*

Parent/Guardian Name:

Relationship:

HOME LANGUAGE QUESTIONNAIRE

Dear Parent or Guardian, 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, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank You.

Language Background

1) What language(s) is(are) spoken in the student's home or residence?

English Other

Specify if Other Checked

2) What was the first language your child learned?

English Other

3) What is the Home Language of each parent/guardian?

Mother

Father

Guardian

English Other Not Applicable

4) What language(s) does your child understand?

English Other

5) What language(s) does your child speak?

Does not speak English Other

6) What language(s) does your child read?

Does not read English Other

7) What language(s) does your child write?

Does not write English Other

Educational History

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

9) Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write English or any other language?

Yes No Unsure

You answered Yes or Not Sure - please explain below:

How severe do you think those difficulties are?

Unsure Minor Somewhat Severe Very Severe

10a) Has your child ever been referred for a special evaluation in the past?

You answered yes, please complete 10b below:

Yes No

10b) If referred for an evaluation, has your child ever received any special education services in the past?

Yes No

Type of Services received:

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

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

11) If there anything else you think is important for the school to know about your child, please indicate below:

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

10c) Does your child have an individualized Education Program (IEP)?

Yes No

OFFICIAL ENTRY ONLY

Qualified Personnel Administering HLQ:

Name:

Position:

If an Interpreter is provided, list name, position and credentials:

Qualified Personnel Reviewing HLQ:

Name:

Position:

Yes No

Oral Interview Necessary?

**Date of Individual Interview:

Administer NYSITELL English Proficient Refer to Language Proficiency Team

Outcome of Individual Interview:

Qualified Personnel Administering NYSITELL:

Name:

Position:

Date of NYSITELL Administration:

Entering Emerging Transitioning Expanding Commanding

Proficiency Level Achieved:

FOR STUDENT WITH DISABILITIES,LIST ACCOMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:

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