please type directly on the solid line. bellmawr school

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Bellmawr School District Registration Forms

Information for Permanent Record Student Name: Gender: Date of Birth: Grade:

Home Address: Street Address City State Zip Code

City/State of Birth: Country of Birth:

If born out of the United States, date entered USA:

Race: (Check all that apply)

☐White ☐Black/African American ☐American Indian/Alaskan ☐Asian ☐Native Hawaiian/Pacific Islander

Ethnicity: (Check One)

☐Hispanic/Latino ☐Non-Hispanic/Latino

Language spoken in thehome:

Requires Translator:

☐Yes ☐No

Are you living in a temporary residence out of necessity because the family lacks a regular or permanent residence of their own? ☐Yes No

If yes, please list present accommodations:

Last district of permanent residency:

Parent/Guardian Information Parent/Guardian #1 Parent/Guardian #2

Name:

Relationship to Student:

Address:

City: Zip:

Home Phone:

Cell Phone:

Work Phone:

Employer:

Email:

Has custody of student? ☐ Yes ☐ No

Name:

Relationship to Student:

Address:

City: Zip:

Home Phone:

Cell Phone:

Work Phone:

Employer:

Email:

Has custody of student? ☐ Yes ☐ No


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Receives mail for student? ☐Yes ☐No*Please indicate primary phone number

Receives mail for student? ☐Yes ☐No*Please indicate primary phone number

Guardianship: ☐ Mother ☐ Father ☐ Joint ☐ Other(A copy of custody/guardianship papers MUST be provided to the school to be kept on file)

Bellmawr School District has an automated phone message system, which is used to inform you of important notification including weather-related school closings, early dismissals, and upcoming events. Which telephone number (usually a cell) should we use to contact you in these situations?

( ) No extensions.

Please list other children living at the same residence: Child’s Name Gender Birth

Date Name of School Currently Attending Grade

Emergency Contact Information Please list persons who would be able to pick up your child if he/she is ill or injured. Do NOT include persons listed on front of this form. We do not release children to anyone under 18 years old. My child may be released to one of the following people when I cannot be reached:

Emergency Contact #1 Name:_________________________________ Relationship to Student:__________________________________

Home Phone:___________________________ Cell Phone:____________________________________________ Emergency Contact #2

Name:_________________________________ Relationship to Student:_________________________________

Home Phone:___________________________ Cell Phone: ___________________________________________ Emergency Contact #3

Name:________________________________ Relationship to Student: __________________________________

Home Phone: __________________________ Cell Phone:____________________________________________

Health Insurance Information Does your child have Health Insurance?

☐Yes If yes, name of insurance company:If yes, name of insurance company:____________________________________________

☐No, NJ FamilyCare provides free or low-cost health insurance for uninsured children and certain lowincome parents. For more information call 800-701-0710 or visit www.njfamilycare.org to apply online.☐Yes, I grant my permission to release my information to NJ FamilyCare☐No, I do not grant permission to release my information to NJ FamilyCare

Signature: Print Name: Date: Written consent required pursuant to 20 U.S.C. 1232g (b)(1) and 34C.F.R. 99.30 (b)

Parent’s Signature: Date:

http://www.njfamilycare.org/


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Former School Information Last School Attended: Grade Completed: Current Grade:

Address: Phone Number:

Does the student current have an Individual Education Plan (IEP)?

Does the student have current a 504 Accommodation Plan? ☐Yes

Has your child ever been referred to the Child Study Team (CST)

Was the student ever previously registered in the Bellmawr School District?

☐Yes ☐No

☐No

☐Yes ☐No

☐Yes ☐No

If yes, what was the last school and grade the student completed?

Did your child ever participate in homeschooling? ☐ Yes ☐ No


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CONFIDENTIAL HEALTH HISTORY

Student Name: Grade: D.O.B. Gender:

Parent/Guardian Name:

Address:

Phone Number: Email:

Child’s Physician: Phone Number:

Preferred Hospital:

My child is covered by medical insurance provided by: ☐ Employer ☐ Self ☐ NJ Family Care ☐ not covered(if not covered please contact your school nurse for information on NJ Family Care)

I. MedicationIs the student on any type of medication at this time? ☐ Yes ☐ NoIf yes, please list medicine, dosage and reason foradministration of same:

II. Infections/illnesses, and Other ProblemsHas your child:

1. Had more than six (6) colds or throat infections each year? ☐Yes ☐No2. Had more than three (3) ear infections? ☐Yes ☐No3. Had trouble hearing? ☐Yes ☐No4. Had his/her hearing tested? ☐Yes ☐No5. Had any trouble seeing? ☐Yes ☐No6. Had his/her eyes tested? ☐Yes ☐No7. Had any trouble with his/her teeth? ☐Yes ☐No

Date of last dental visit? __________________8. Had any trouble passing his/her urine? ☐Yes ☐No9. Check any of the following that your child has had:☐Strep infection ☐Rheumatic Fever ☐Speech impediment☐10 day Measles ☐Headaches ☐Bedwetting☐3 day Measles ☐Blackouts Poor ☐Concentration☐Mumps ☐Epilepsy ☐Concussion☐Scarlatina ☐Convulsions ☐Over-activity☐Pneumonia ☐Vision Problems ☐Temper Tantrums☐Whopping Cough ☐Un-coordination ☐Aggressiveness☐Chicken Pox ☐Hearing Loss ☐Brain Trauma


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10. Has your child had any other diseases or problems? ☐Yes ☐No If yes, please list them:

CONFIDENTIAL HEALTH HISTORY CONTINUED

11. Has your child had stay in the hospital overnight? ☐Yes ☐No

Age: Hospital: Reason:

12. Has your child had any operations or serious accidents? ☐Yes ☐No If yes, explain:

III. Dental Examination My child is seen by the dentist annually ☐Yes ☐No IV. Allergies/Asthma (check if applicable) ☐Wheezing ☐Reaction to Penicillin ☐Hives ☐Eczema ☐Reaction to medication ☐Hay fever ☐Asthma ☐Reaction to insect bites Additional information on any of the above:

V. Nutrition

Food allergies: Appetite: ☐Good ☐Fair ☐Poor

Unusual weight gain or weight loss: VI. Summary Is there anything in regard to your child’s health and/or behavior you would like to comment upon?

I hereby give permission for my child to receive the following medical attention as part of the school health program in the Bellmawr Public School District. (Please initial “yes” or “no” for all items listed.)

1. Treatment by the school nurse or designee in case of illness or injuries. ☐Yes ☐No 2. Annual vision and hearing screening. ☐Yes ☐No 3. Scoliosis screening by the school nurse for students ages 10-18 ☐Yes ☐No

Parent/Guardian Signature:

Date:


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Parent Authorization for Release of School Records Name of school previously attended:

School Address:

School Phone Number: School Fax Number:

Student Name Date of Birth Grade

In accordance with the New Jersey Administrative Code Inspection of School Records, the above-name school is hereby authorized to release to the school named below all school records, including NJ State ID#, grades, health, medical, psychological, social, educational, developmental and discipline records.

Request for Transcript of School Records

Please send all academic school records to the school selected below:

☐ Bell Oaks Upper Elementary School ☐ Bellmawr Park School 256 Anderson Avenue 29 Peach Road Bellmawr, NJ 08031 Bellmawr, NJ 08031 856-931-6273 856-931-6272 ☐ Ethel M. Burke School 112 S. Black Horse Pike Bellmawr, NJ 08031 856-931-6362 Parent/Guardian Name:


Date:


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Primary Information: Proof of Residency - Please Read Before Proceeding

The questions asked in the following pages will enable us to determine your student’s eligibility to attend school in this district in accordance with New Jersey law. Please be aware that N.J.S.A. 18A:38-

1 and N.J.A.C. 6A:22 require that a free public education be provided to students between the ages of 5

and 20, and to certain students under 5 and over 20 as specified in other applicable law, who are:

• Domiciled in the district, i.e., the child of a parent or guardian, or an adult student, whose permanent home is located within the district. A home is permanent when the parent, guardian or adult student intends to return to it when absent and has no present intent of moving from it, notwithstanding the existence of homes or residences elsewhere

• Living with a person, other than the parent or guardian, who is domiciled in the district and is supporting the student without compensation, as if the student were his or her own child, because the parent cannot support the child due to family or economic hardship

• Living with a person domiciled in the district, other than the parent or guardian, where the parent/guardian is a member of the New Jersey National Guard or the reserve component of the U.S. armed forces and has been ordered into active military service in the U.S. armed forces in time of war or national emergency

• Living with a parent or guardian who is temporarily residing in the district • The child of a parent or guardian who moves to another district as the result of being homeless • Placed in the home of a district resident by court order pursuant to N.J.S.A. 18A:38-2

• The child of a parent or guardian who previously resided in the district but is a member of the New Jersey National Guard or the United States reserves and has been ordered to active service in time of war or national emergency, resulting in relocation of the student, pursuant to N.J.S.A. 18A:38-3(b)

• Residing on federal property within the State pursuant to N.J.S.A. 18A:38-7.7 et seq. Note that “guardian” means a person to whom a court of competent jurisdiction has awarded

guardianship or custody of a child, provided that a residential custody order shall entitle a child to attend

school in the residential custodian’s school district subject to a rebuttable presumption that the child is

actually living with such custodian; it also means the Department of Children and Families for purposes

of N.J.S.A. 18A:38-1(e). Also note that a student is entitled to attend school in the district of domicile

notwithstanding that the student is qualified to attend school in a different district as an “affidavit”

student or temporary resident.

Note that the following do not affect a student’s eligibility to enroll in school:

• Physical condition of housing or compliance with local housing ordinances or terms of lease • Immigration/visa status, except for students holding or seeking a visa (F-1) issued specifically for

the purpose of limited study on a tuition basis in a United States public secondary school.


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• Absence of a certified copy of birth certificate or other proof of a student’s identity, although these

must be provided within 30 days of initial enrollment pursuant to N.J.S.A. 18A: 36-25.1

• Absence of student medical information, although actual attendance at school may be deferred as necessary in compliance with rules regarding immunization of students, N.J.A.C. 8:57-4.1 et seq.

• Absence of a student’s prior educational record, although the initial educational placement of the student may be subject to revision upon receipt of records or further assessment by the district.

The following forms of documentation may demonstrate a student’s eligibility for enrollment in the district. Particular documentation necessary to demonstrate eligibility under specific provisions in law will be indicated in the appropriate section of the registration form.

• Property tax bills, deeds, contracts of sale, leases, mortgages, signed letters from landlords and other

evidence of property ownership, tenancy or residency.

• Voter registrations, licenses, permits, financial account information, utility bills, delivery receipts, and other evidence of personal attachment to a particular location.

• Court orders, State agency agreements and other evidence of court or agency placements or directives • Receipts, bills, cancelled checks and other evidence of expenditures demonstrating personal attachment to a particular location, or, where applicable, to support of the student.

• Medical reports, counselor or social worker assessments, employment documents, benefit statements, and other evidence of circumstances demonstrating, where applicable, family or economic hardship, or temporary residency.

• Affidavits, certifications and sworn attestations pertaining to statutory criteria for school attendance, from the parent, guardian, person keeping an “affidavit student,” adult student, person(s) with whom a family is living, or others as appropriate.

• Documents pertaining to military status and assignment • Any business record or document issued by a governmental entity.

• Any other form of documentation relevant to demonstrating entitlement to attend school.

The totality of information and documentation you offer will be considered in evaluating an application, and, unless expressly required by law, the student will not be denied enrollment based on your inability to provide certain form(s) of documentation where other acceptable evidence is presented.

You will not be asked for any information or document protected from disclosure by law, or pertaining to criteria which are not legitimate bases for determining eligibility to attend school. You may voluntarily disclose any document or information you believe will help establish that the student meets the requirements


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of law for entitlement to attend school in the district, but we may not, directly or indirectly, require or request:

• Income tax returns • Documentation/information relating to citizenship or immigration/visa status, unless the student

holds or is applying for an F-1 visa • Documentation/information relating to compliance with local housing ordinances or conditions of

tenancy. • Social security numbers

Please be aware that any initial determination of the student’s eligibility to attend school in this district is subject to more thorough review and subsequent re-evaluation, and that tuition may be assessed in the event that an initially admitted student is later found ineligible. If your student is found ineligible, now or later, you will be provided the reasons for our decision and instructions on how to appeal. Your signature below indicates that you have read and understand the above information. Signature: Date:

If you have difficulties with the registration process, please contact the office of the Superintendent at 856-931-3620 ext. 1313.


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Student Name:

Dear Parent/Guardian: The Bellmawr Board of Education has policies and procedures related to “Proof of Domicile” for students who attend our schools. The District shall only provide a free education to those students who are domiciled within the District or who otherwise qualify for a free education pursuant to the statutory and regulatory guidelines set forth in N.J.S.A. 18A:38-1 et seq. A student shall be domiciled in the District “when he or she is living with a parent or legal guardian whose permanent home is located within the District. “N.J.A.C. 6A: 22-3.1. the home is permanent if “the parent or guardian intends to return to it when absent and has no present intent of moving from it.” If the District discovers that a student is attending school whose parents are not domiciled within the District, they may apply for the student’s removal and seek tuition reimbursement for the period of ineligible attendance in accordance with the provisions of N.J.S.A.18A:38-1(b) (2).

Applicants who fraudulently allow a child of another to use his residence, or who fraudulently claim to have of a child, may be charged with a disorderly person offense. N.J.S.A. 18A:38-1 (C). If the applicant is convicted of such an offense, the applicant may be fined up to $1000.00 and/or be imprisoned for up to 6 months.

Any false statements, answers or declarations contained in the Affidavit or in an application for admission may subject the applicant to criminal prosecution for the crime of false swearing, in violation of N.J.S.A. 2C:43-3. If convicted for such a crime, the applicant may be punished by a fine of $10,000.00 and/or be imprisoned for up to 18 months.

I, the undersigned, hereby acknowledge that I have read and understood the contents of this notification.

Signature of Parent/Guardian Date

Printed Name of Parent/Guardian


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BELLMAWR PUBLIC SCHOOLS 256 Anderson Avenue Bellmawr, NJ 08031

(856) 931-3620

Affidavit for adults unable to provide residency proof pursuant to NJSA 18A:38:1

Name of Student:

Date of Birth:

Previous Address of Student:

Previous School: Grade:

I, Owner(s) Renter(s) Name(s) Rent or Own

The property at: , New Jersey. (Address)

. I further swear that

(Student) (s)

and Reside with me on a full-time basis, (Parent/Guardian)

also maintaining a permanent residence at this address.

I have initialed here To acknowledge that I will notify the Office of the Superintendent immediately when this student no longer legally resides at this Bellmawr Public School address on a full-time basis.

I have read this Affidavit of Residency, that I have completed, and it is true and correct. I understand that I can be held legally responsible for any violation of NJSA 18A:38-1.c as a Disorderly Person for fraudulently allowing the use of my residence for the purpose of receiving a free education in this district. I also understand that I may be charged tuition for the number of days attended under a fraudulent affidavit.

Resident Owner/Renter Signature Home Phone:

Work Phone:

Parent Guardian Signature Date:

Sworn to and subscribed before me the day of 20

Notary Public


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Special Education Medicaid Initiative (SEMI) Parental Consent Form

Our school district is participating in the Special Education Medicaid Initiative (SEMI) program that allows school districts to bill Medicaid for services that are provided to students.

In accordance with the Family Educational Rights and Privacy Act, 34 CFR § 99.30 and Section 617 of the IDEA Part B, consent requirements in 34 CFR § 300.622 require a one-time consent before accessing public benefits.

This consent establishes that your child’s personally identifiable information, such as student records or information about services provided to your child, including evaluations and services as specified in my child’s Individualized Education Program (IEP) (occupational therapy, physical therapy, speech therapy, psychological counseling, audiology, nursing and specialized transportation,) may be disclosed to Medicaid and the Department of the Treasury for the purpose of receiving Medicaid reimbursement at the school district.

As parent/guardian of the child named below, I give permission to disclose information as described above and I understand and agree that Medicaid may access my child’s or my public benefits or insurance to pay for special education or related services under Part 300 (services under the IDEA).

I understand that billing for these services by the district does not impact my ability to access these services for my child outside of the school setting, nor will any cost be incurred by my family including co-pays, deductibles, loss of eligibility or impact on lifetime benefits.

Child’s Name:

Child’s Date of Birth: Parent/Guardian:

Date: / /

I give consent to bill for SEMI: ☐ Yes ☐ No This consent can be revoked at any time by contacting the administrator at your child’s school.


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Preschool Home Language Survey Only complete if your child is in preschool.

Parent/Guardian Questionnaire

PLEASE PRINT Child’s name: Date of birth: (first) (middle) (last)

Date of school entrance:

Person completing the survey: ☐Mother ☐Father ☐Grandparent ☐Guardian ☐Other Please tell us about your child: 1. What language did the child learn when he/she first began to

talk?

2. What language does the family speak at home most of the

time?

3. What language(s) does the primary caregiver(s) speak to the child most of the

time?

4. What language(s) does the child speak to his/her primary caregiver(s) most of the

time?

5. What language (s) does the child speak to his/her brothers and sisters most of the

time?

6. What language does the child speak to his/her friends most of the

time?

7. Please list any preschool program(s) your child attended before coming to our program:

8. In which language do you wish to receive information from the school?

9. What name do you use for your child (if different from above)?

Please complete if your child is entering Preschool.


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Bellmawr Public School District Registration Forms

Home Language Survey Form For Students in Grades K-8

Instructions Start with “Question 1” and continue until the Home Language Survey is complete. Select the answer for each question and follow the instructions.

Student Information

Student Name: Student Birth Date:

Street Address:

City: State: Zip Code:

Phone Number:

Survey Questions Question 1 What was the first language used by the student?

☐ A language other than English.☐ English.

Question 2 At home, does the student hear or use a language other than English more than half of the time?

☐ Yes. ☐ No.

Question 3 Does the student understand a language other than English?

☐ Yes. ☐ No.

Question 4 When interacting with his/her parents or guardians, does the student use a language other than English mor than half of the time?

☐ Yes. ☐ No.

Question 5 When interacting with caregivers other than their parents or guardians, does the student use a language other than English more than half of the time?

☐ Yes. ☐ No.

Question 6 Has the student recently moved from another school district/charter school where he/she was identified as an English language learner?

☐ Yes. ☐ No.

Question 7 What are the home languages spoken? List below


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GENESIS PARENT PORTAL Our Genesis Parent Portal is now open for all parents. Please complete this form and return it with your registration packet.

Please Print Clearly Parent/Guardian Information

Parent/Guardian Name: Relationship to Student:

Telephone No: Email:

I certify that I am the legal guardian of the student(s) listed below and wish to gain access to the Genesis Parent Portal. Parent/Guardian Signature: Date:

Student(s) Information Student Name: Grade:

Date of Birth:

Student Name: Grade:

Date of Birth:


Date of Birth:


Date of Birth:


Date of Birth:


P. 16


Internet Permission Form for Students

We are pleased to offer students in the Bellmawr Public Schools access to the district computer network for the Internet. To gain access to the Internet, all students under the age of 18 must obtain parental permission and must sign and return this form to the classroom teacher. Access to the Internet will enable students to explore thousands of libraries, databases, and bulletin boards while exchanging messages with Internet users throughout the world. Families should be warned that some material accessible via the Internet may contain items that are illegal, defamatory, inaccurate, or potentially offensive to some people. While our intent is to make Internet access available to further educational goals and objectives, despite our best efforts, students may find ways to access other materials as well. We believe that the benefits to students from access to the Internet, in the form of information resources and opportunities for collaboration, exceed any potential disadvantages. Ultimately, parents and guardians of minors are responsible for setting and conveying the standards that their children should follow when using media and information sources. To that end, the Bellmawr Public Schools support and respect each family’s right to decide whether or not to apply for access. Direct Internet and E-Mail Rules Students are responsible for good behavior on school computer networks just as they are in a classroom or a school hallway. Communications on the network are often public in nature. General school rules for behavior and communications apply. The network is provided for students to conduct research and communicate with others. Access to network services is given to students who agree to act in a considerate and responsible manner. Parental permission is required. Access is a privilege, not a right, and it requires parental permission. Individual users of the district computer networks are responsible for their behavior and communications over those networks. It is presumed that users will comply with district standards and will honor the agreements they have signed. Beyond the clarification of such standards, the district is not responsible for restricting, monitoring, or controlling the communication of individuals utilizing the network. Network storage areas may be treated like school lockers. Network administrators may review files and communication to maintain system integrity and ensure that users are using the system responsibly. Users should not expect that files stored on district servers will always be private. However, within reason, freedom of speech and access to information will be honored. During class, a teacher will guide students toward appropriate materials. Outside of school hours, families bear the same responsibility for guidance as they might exercise with information source such as television, telephones, movies, radio, and other potentially offensive media. As outlined in Board policy and procedures on students’ rights and responsibilities, copies or which are available in school offices, the following are not permitted:

* Sending or displaying offensive messages * Using another’s password * Sending or displaying offensive pictures * Using or sending obscene language * Trespassing in another’s folders, work, or files * Harassing, insulting, or attacking others * Employing the network for commercial purposes * Damaging computers, computer systems * Intentionally wasting limited resources * Computer networks, or violating copyright laws

I understand that violations may result in a loss of access as well as other disciplinary or legal action. As a user of the Bellmawr Public Schools Computer Network, I hereby agree to comply with the above stated rules. As the parent or legal guardian of the minor student signing above, I grant permission for my son or daughter to access network computer services such as electronic mail and the Internet. I understand that individuals may be held liable for violations of the user rules and provisions. I understand that some material on the Internet may be objectionable. I accept responsibility, along with the Bellmawr Public School District, to set and convey standards for my son or daughter to follow when using the Internet. These are the same standards I might exercise when selecting, sharing, or exploring information sources such as television, telephones, movies, radio, books, etc. I understand that the Access to Information Software and Computing Agreement my son or daughter signed is a binding agreement and will be supported by me as a parent or legal guardian.

Parent/Guardian Signature: Date:


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Media Release Form

Student Name: Grade: School:

Public Relations Permission Bellmawr School District has a proud tradition of celebrating student accomplishments by sharing them with our community. Occasionally, local newspapers and television stations come to Bellmawr School District to report these special accomplishments and/or events that take place at our school, which at times they photograph or film students participating in these special events. In addition, the district maintains a website and publishes a newsletter that includes individual school happenings and may include pictures of students.

☐ Yes – I consent. I grant permission to use my child’s name and/or picture.

☐ No – I do not consent permission to use my child’s name and/or picture.

PTO Permission Form The Parent-Teacher Organization (PTO) provides a valuable service to our schools and helps parents get involved with their child’s education. Do you give permission for the school to share your name, address, phone number and/or email address with the PTO for communication purposes? No additional information will be shared.

☐ Yes – I consent, I grant permission to the school to share my information with the PTO.

☐ No – I do not consent permission for the school to share my information with the PTO.

Email Address Form At times during the school year, we will distribute information and announcements via email. Please supply us with your email address and an alternate email if possible.

Email Address:

Alternate Email Address (if applicable:)

Student Cell Phone On occasion, the need arises to reach a student outside of the school day (school trips, activities, athletic events, or emergencies). If your child has a cell phone and you would like us to have access to the number for the purposes listed above, please list the number here:

Please sign to indicate that you read and checked a box in each section above.

Parent/Guardian Name:


Date: