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Town of Lincoln Public SchoolsDistrict Registration Checklist

DOCUMENTS/INFORMATION NEEDED FOR REGISTERING A NEW STUDENT IN THE LINCOLN PUBLIC SCHOOLS. ALL LINES ON EVERY SHEET MUST BE FILLED IN._____ PARENT PHOTO IDENTIFICATION (I.E., LICENSE/PASSPORT) – ID WILL BE VERIFIED BY STAFF_____ REGISTRATION FORM COMPLETED_____ PROOF OF RESIDENCY_____ STATE OF RHODE ISLAND PHYSICAL FORM COMPLETED AND SIGNED BY A PHYSICIAN _____ CURRENT IMMUNIZATIONS _____ HEALTH QUESTIONNAIRE_____ HOME LANGUAGE SURVEY (Please make sure the Home Language Survey has ALL DATES filled in)_____ RECORDS RELEASE_____ CHILD’S ORIGINAL BIRTH CERTIFICATE/PASSPORT ______LEGAL GUARDIANSHIP/CAREGIVER AFFIDAVIT DOCUMENTS (IF APPLICABLE) ______LEGAL/PHYSICAL CUSTODY ORDERS/SEPARATION AGREEMENT (IF APPLICABLE) _____ SPECIAL EDUCATION: INDIVIDUAL EDUCATION PLAN/TESTING 504 PLAN (IF APPLICABLE) _____ INTERNATIONAL STUDENTS (COPY OF CHILD’S & PARENT’S PASSPORT AND ANY VISA J,L, R, G NOT B1 OR B2)_____ STUDENT RECORDS/TRANSCRIPTS/REPORT CARDS

PROOF OF RESIDENCY RENTER______ LEASE (MUST BE NOTARIZED OR ACCOMPANIED BY A NOTARIZED LETTER FROM THE LANDLORD)______ONE CURRENT UTILITY BILL (GAS, OIL, ELECTRIC, TELEPHONE) OR EXCISE TAX BILL, CAR INSURANCE STATEMENT, RHODE ISLAND CAR REGISTRATION

HOMEOWNER ______MORTGAGE STATEMENT (ESTABLISHED HOMEOWNERS) ______EXECUTED PURCHASE AND SALES AGREEMENT WITH CLOSING DATE/MORTGAGE STATEMENT (NEW HOMEOWNERS) ______ONE CURRENT UTILITY BILL (GAS, OIL, ELECTRIC, TELEPHONE, CABLE) OR PROPERTY TAX BILL, FIRE TAX BILL, WATER BILL, EXCISE TAX BILL, CAR INSURANCE STATEMENT, RHODE ISLAND CAR REGISTRATION____________________________________________________________________________________

Office Use Only

Student Start Date _____________________________

Office Approval to Attend _______________________ Approval by Nurse _____________________________

Bus Company Contacted ________________________ Bus # __________________

Revised 1/17/18

Town of Lincoln Public Schools District Registration

Date of Entry:

Grade:

Child’s Name: Sex: M F Last First Middle

Date of Birth: ____________________________Place of Birth: ________________________________

Child’s Address: _________________________

Home Phone: ______________________________

Which of the following best describes your child? (Please circle one) Alaskan Native American Asian Pacific Islander Hispanic Black (non-Hispanic) White (non-Hispanic)

Enrollment is based on space availability; therefore, a student’s school assignment may be subject to change.

Father’s Name: ________________________ Address: Home Phone: ____Email address: ____

Employer: Cell Phone: ___

Mother’s Name: ________________________ Address: Home Phone: ___ Email address: ___

Employer: Cell Phone: __

Child Resides With: _

Legal Guardian: _**Question of Custody will be clarified with the School Principal

Other Children in the Family:

Age

_ Age _

Age

_ Age _

For Kindergarten Students only

Child’s Name _____________________________________________________

Has the child attended preschool? ____________________________________

Name of Preschool(s) ______________________________________________

______________________________________________

How many years? _________________________________________________

2 original PROOF OF RESIDENCY DOCUMENTS REQUIRED:Homeowner: Mortgage statement or Purchase & Sale agreement with closing dateRenter: Lease agreement (must be notarized OR accompanied by a notarized letter from the landlord) AND one of the following:

Utility Bill (gas, electric, telephone, cable) Property/Fire Tax Bill Water Bill Excise Tax Bill Car Insurance Statement RI Car Registration

Signature of Person providing this information:

Information: _ Relationship:

Date: _

Mandatory Information for Rhode Island Department of Education(Middle and High School Only)

Guidance Counselor __________________________________

Year of Graduation ___________

Language Regularly Spoken at Home _

Has your child ever attended Lincoln Public Schools before? Where: Years:

School Transferring From: _

Address of Previous School: Phone:

Please list two (2) people, other than parents, who could be contacted in case of an emergency:

1. Name: _ Relationship:

Address: __ Phone: ___

2. Name: _ Relationship: ___

Address: _ Phone: ___

Emergency information must remain current. Please notify the schools of any change.

Town of Lincoln Public Schools District Records Release Form

Date: / /

I hereby authorize the School District of: Name of Previous School: ____________________________________ Address: __________________________________________________ Phone: __________________________ Fax: _____________________

To release the complete school/confidential records (including health and academic records) andIEP Records if applicable in your possession concerning my child.

Name:

Date of Birth: / /

Release Records to:Circle One

Saylesville Elementary 50 Woodland StreetLincoln, RI 02865P (401) 723-5240F (401) 722-1090

Lincoln Middle School 152 Jenckes Hill Road Lincoln, RI 02865P (401) 721-3400F (401) 721-3428

Northern Elementary 315 New River Rd. Manville, RI 02838P (401) 769-0261F (401) 765-0530

Lincoln High School 135 Old River Road Lincoln, RI 02865P (401) 334-7500F (401) 334-8753

Central Elementary 1081 Great RoadLincoln, RI 02865P (401) 334-2800F (401) 334-4294

Lonsdale Elementary 270 River RoadLincoln, RI 02865P (401) 725-4200F (401) 722-0920

Parent/Guardian Signature:

Relationship to child:

Student’s Name__________________________________DOB____________________Grade_____

STUDENT HEALTH SECTION

Physician’s Name __________________________________Phone Number__________________

IF YOU ANSWER YES TO ANY QUESTION, PLEASE EXPLAIN 1. Has your child ever had any operations or serious illnesses? Yes No If yes, please explain: ________________________________________________ 2. Has your child had any serious accidents? Yes No If yes, please explain: ________________________________________________ 3. Does your child wear eyeglasses, contacts, braces, hearing aids, or any Yes No other corrective devise? If yes, please explain: ________________________________________________ 4. Has your child had the following (Give month, year and/or age if known):

Chicken Pox __________________Yes No Heart Condition ________________Yes NoPneumonia __________________ Yes No Diabetes ______________________Yes NoNosebleeds __________________Yes No Seizures ______________________Yes NoFrequent sore throats __________Yes No High Fevers ___________________ Yes NoEar Infections ________________ Yes No Migraines ____________________ Yes NoEye Condition ________________ Yes No Other (Please specify) ___________Yes No

5. Has your child been screened by a Speech/Language Therapist? Yes No If yes, where? ______________________________________________________ 6. Has your child had a neurological evaluation? Yes No If yes, when? _______________________________________________________ 7. Has your child had a psychological evaluation? Yes No If yes, when? _______________________________________________________ 8. Is your child restricted from physical activities? Yes No If yes, please explain: ________________________________________________ 9. Is your child allergic to: medicines/drugs? Yes No If yes, please specify: ________________________________________________ Is your child allergic to: plants/foods? Yes No If yes, please specify: ________________________________________________ Is your child allergic to: insect stings? Yes No If yes, please specify: ________________________________________________

10. If you answered yes to question #9, does your child take medication for this allergy? Yes No

If yes, please specify (i.e. Benadryl, Epi-Pen, etc.): ___________________________

11. Does your child have asthma? Yes No If yes, what was the date diagnosed? _____________________________________ If yes, what medication(s) does he/she take? _______________________________ 12. Does your child take any daily medications? Yes No If yes, please specify: __________________________________________________ 13. Will medication be given at school? Yes No If yes, please specify: __________________________________________________ 14. What medications are given frequently, but not daily? _______________________ 15. Would you like a conference with the school nurse? Yes No

Parent Name (Please Print) _____________________________________________________

PARENT SIGNATURE: _____________________________________ DATE: _______________

School Name & Address: Health Care Provider Name and Address:

STATE OF RHODE ISLAND SCHOOL PHYSICAL FORM Phone:

This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4)Student Name: Last First Middle Date of Birth Sex

Address: Street Apt # City State Zip Code Home Phone

PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript).IMMUNIZATIONS Please enter dates in MM/DD/YYYY format

Hepatitis B

Diphtheria-Tetanus-Pertussis DTP/DTaP Check if DT Check if DT Check if DT Check if DT Check if DT

Pneumococcal Conjugate PCVPolio

Haemophilus Influenzae Type B Hib

Measles-Mumps-Rubella MMR

Varicella Student has history of varicella disease

Tetanus-Diphtheria-Pertussis TdaP/Td Check if Td Check if Td Check if Td

Rotavirus

Hepatitis A

Meningococcal

HPV

Immunization Exemption: D Medical D Religious

Hep B DTaP PCV Polio Hib MMR Varicella Td/Tdap Rotavirus Hep A Mening HPVPHYSICAL EXAMINATION

Date of PE / / Height Weight BP

Please note any health problem, chronic health condition or disability that may affect behavior or health at school:

ASTHMA: No Yes DIABETES: No Yes OTHER:

Significant Systems Findings:

ALLERGIES: No Yes (Please explain) EPINEPHRINE AUTO-INJECTOR REQUIRED: No Yes

Treatment Plan:

MEDICATION (REQUIRED AT SCHOOL): No Yes (Please list)

Other medication(s) that may affect behavior or health at school:

RESTRICTIONS: Can participate in physical education: FullyD With limitation D

Can participate in sports: FullyD With limitation D

LEAD SCREENING (Required for children < 6 years of age only)Student is in compliance with lead screening requirements:

Yes D No D

SCOLIOSIS SCREENINGYes D No D

VISION SCREENING (Children entering Kindergarten)D Passed screeningD Screened and referred for comprehensive examD Referred for comprehensive exam, but not screened

TUBERCULOSIS (If required by school district)Date of TB test:

Screening Date: Comprehensive Exam Date:

HEALTH CARE PROVIDER SIGNATURE: DATE:

PRINT NAME:

Revised 8-09

State of Rhode Island and Providence PlantationsDEPARTMENT OF EDUCATIONShepard Building255 Westminster StreetProvidence, Rhode Island 02903-3400

Deborah Gist Commissioner

RHODE ISLAND HOME LANGUAGE SURVEYThe information requested on this form is necessary for the most appropriate placement for your child as required by Rhode Island Law (R.I.G.L. § 16-54-2) and the Equal Educational Opportunity Act (20 U.S.C.§1703(f)) and will not be used for any other purposes. Thank you for your cooperation.

To be completed by parent or guardian:

Student Name: Country of Birth

Registration Date ofDate:

Birth: _Date entered United States:_

1. What language do you use most often when speaking to your child?

2. What language did your child first learn to speak?

3. What language does your child use most often when speaking to you?

4. What language does your child use most often when speaking to other adults in the home or to their primary caretaker?

5. What language does your child use most often when speaking to siblings or other children in the home?

6. What language does your child use most often when speaking to friends or neighbors outside the home?

Signature of Parent or Guardian Date

Print Parent/Guardian Name

Telephone (401)222-4600 Fax (401)222-6178 TTY 800-745-5555 Voice 800-745-6575

The Board of Regents does not discriminate on the basis of age, color, sex, sexual orientation, race, religion, national origin, or disability

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BUS TRANSPORTATIONSTUDENT DATA FORM

The information requested below will be used to update and or assign students in the Versa-Trans computerized routing system. This system enables us to provide you with timely and accurate information. Please fill out this form if bus transportation is requested.(School secretary: please fax this form immediately upon completion to First Student at 401-334-0576)

DATE: ________________________

PLEASE CIRCLE ONE:

NEW STUDENT CHANGE DELETION

NAME: ________________________________________________________________

ADDRESS: ______________________________________________________________

PARENT/GUARDIAN: ____________________________________________________

TELEPHONE # _____________________ ALTERNATE # ______________________

SCHOOL: ____________________________________ GRADE: _______________

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For First Student Bus Co. use only

BUS IN _______ STOP __________________________________ TIME ________

BUS OUT ______ STOP __________________________________ TIME ________