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Student Registration Form

STUDENT INFORMATION
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HOUSING

The answer you give to the following question will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don't have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

Your answer will be kept confidential and will only be shared with those staff responsible for providing services to the student and those responsible for keeping track of how many students are identified as living in temporary housing.

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OFFICE USE ONLY

SUPPORT SERVICES

In previous school did student receive Special Education with an Individualized Education Program (IEP)?

In previous school did student have a 504 Plan?

In previous school did student receive  Academic Intervention Services or Support (sometimes called RTI, AIS or Title 1)?

In previous school did student receive support for English as a Second Language (ESL) or English as a New Language (ENL)?

Is this child dealing with stress such as: a new baby, illness, a death in the family, separation/divorce of parents, loss of a pet, loss of friends due to moving etc.? If so, please explain:

STUDENT RACE/ETHNICITY

All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.

The Gouverneur Central School District requires the collection and recording of the ethnic identity of students in the Gouverneur School District in accordance with the Federal categories and definitions. The information will be used to:

           *  Report information to the State and Federal Education Departments.

           *  Plan educational programs and make sure they are readily available to all students.

           *  Analyze differences in the academic performance, attendance and completion of school.

The Gouverneur Central School District understands the sensitive nature of this information and wishes to assure you the your answers to the following two (2) questions will be kept secure and confidential in accordance with all State and Federal privacy laws and regulations.

         

Is the student Hispanic, Latino, or of Spanish origin? 

 

(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.)

Check one or more groups from the following list that best describes your child's race:

 

 

 

 

 

 

 

 

A person having origins in any of the original peoples of North and South America (including Central America) and who maintains cultural identification through tribal affiliation or community recognition (e.g. Cherokee, Mohawk,  Inuit).

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example,  Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

A person having origins in any of the black racial groups of Africa.

A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

HOME LANGUAGE QUESTIONNAIRE (HLQ)

In order to provide your child with the best possible education, we need to determine how well they understand, speak, read and write in English.

Language Background  (Please check all that apply)

 

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

What was the first language your child learned?

What is the Home Language of each parent/guardian?

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?

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

OFFICE USE ONLY

UNPLANNED EARLY DISMISSAL PLAN

IF SCHOOL CLOSES EARLY, WHERE SHOULD YOUR CHILD GO? (for unplanned, early closings.....Please list the Person's Name, Address, Phone# and indicate Bus Name or Walker)

In case of UNPLANNED, early dismissal, the school will follow the instructions you have provided above. This information will override any notes for that day unless the note specifically states that it should be followed in the case of early dismissal. It is very important to your child's safety that this information is kept current. Changes cannot be accepted over the phone.

STUDENT RELEASE INFORMATION & EMERGENCY NOTIFICATION

According to New York State Law (S 7737) schools can only release the student to the persons whose name appears on a list provided by the parents or guardian.

List three alternate persons (with address & telephone) to be notified in case of emergeny, when parents cannot be reached. These persons will also be allowed to pick up your child at school. This signed form will serve as your pre-signed permission for release of your child at any time. IT IS NOT NECESSARY TO LIST PARENTS OR LEGAL GUARDIANS.

             REMINDER:     1. Authorized individuals are to pick up children at the school office only (not classroom).

                                     2. Changes in this list must be submmited on new forms at the school office.

                                     3. If necessary, we may request identification before releaseing your child.

                                     4. We will release your child only to the persons who are listed below.

GOVERNMENT INFORMATION

Is a parent or guardian at the home address employed by the military?

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REQUEST FOR RELEASE /TRANSFER OF SCHOOL RECORDS

 

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The following student is registering in the Gouverneur Central School District:

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I HEARBY AUTHORIZE THE ABOVE SCHOOL TO RELEASE ALL CONFIDENTIAL INFORMATION FROM THE ABOVE STUDENT’S RECORDS TO:  

THIS CONFIDENTIAL INFORMATION INCLUDES:

ACADEMIC INFORMATION

HEALTH AND IMMUNIZATION RECORD

PHYSICAL EXAM

ATTENDANCE RECORDS

TITE I/AIS RECORDS

NYSITELL

NYSESLAT

GIFTED/TALENTED/ENRICHMENT INFORMATION

BIRTH CERTIFICATE

CUSTODY INFORMATION

DISCIPLINE/SUSPENSION RECORDS

CSE/PSYCHOLOGICAL RECORDS

ENL

 

Current Signature
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IN ACCORDANCE WITH PUBLIC LAWS 93-380: FAMILY EDUCATION RIGHTS AND PRIVACY ACT OF 1972, THIS IS AUTHORIZATION TO RELEASE A COPY OF STUDENT RECORDS (INCLUDING COMPLETE TRANSCRIPT OF THE SCHOOL RECORD, STANDARDIZATION TEST RESULTS, HEALTH RECORDS AND PSYCHOLOGICAL REPORTS).

PREVIOUS SCHOOLING
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Grade(s)
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School
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Location/State
PRE-SCHOOL SIBLINGS (not old enough to attend school)


PARENT/GUARDIAN INFORMATION

Parent / Guardian 1

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 Parent / Guardian 2

3. Please identify any custodial information relevant to the health, safety and welfare of the child that the school should be aware of:

SAFE SCHOOLS REGISTRATION FORM - STUDENT ENROLLMENT

I am the parent/legal guardian of                                                           and I am providing this affidavit in support of the enrollment of my child in school. I understand that it is a criminal offense to give false information concerning prior disciplinary actions taken against my child. I also understand that if this school district admits my child based on false information which I gave, my son/daughter's enrollment will be nullified.

UNDER PENALTY OF PERJURY, i swear (or affirm) that the legal papers submitted and questions answered above for the Gouverneur Central School District on this              day of                      , 20            with respect to the custody arrangments for                                                              are current, valid and still in effect, and that there are no legal documents with any later date that alter the custody arrangement set forth in these papers.

Current Signature
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Gouverneur Central School District

133 East Barney Street

Gouverneur, New York 13642

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