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WEST BABYLON UNION FREE SCHOOL DISTRICT

Pupil’s Name ________________________________________________________________________________ Last First Middle Date __________ ID#______________ Lunch #___________ Enrollment Date ___________ Address ___________________________________________________ Bus Walker Home Telephone # ______________________________________Cell # _______________________________ Date of Birth (DOB) ____________________ Student Gender: Male Female M/D/YR Residence Type: Own Move in Date _____________________________

Rent Rental/Lease Expires: _____________________ Parent/Guardian Information:

Father’s Name ___________________________________________________ ________________________ Last First Language Spoken E-mail address ______________________________________________________ Home Address (if different from student): ____________________________________________________ Business Address: ___________________________________________Phone __________________________

Mother’s Name ____________________________________________ ___________________________ Last First Language Spoken E-mail address ________________________________________________ Home address if different from student:_________________________________________________ Business Address: ___________________________________Phone___________________________

Other children in Family: ________________________________ ______________________________ ___________________________________ Name DOB Name DOB Name DOB

Family Physician (name & phone number) ____________________________________________________________________________________________

Pupil Resides with (Other than parent); Name Address Relationship

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Student Entering West Babylon School _________________________Entering Grade: _________ From: (for a transfer student, release of records to be filled out) School _________________________ Grade _______ Previous School District __________________ Last Day Attended:______________________________ Has Child attended school in West Babylon before: NO YES If yes, name of school ___________________________________________ Proof of Age: One (1) Original Birth Certificate Baptismal Certificate Passport

Proof of Guardianship (Parental Relationship) (Submit one original document) _____1. Birth certificate indicating parent(s) names along with parent’s photo ID (i.e. license) _____2. Baptismal certificate indicating parent(s) names along with parent’s photo ID _____3. Duly executed court documents indicating legal guardianship, along with legal guardian’s photo ID _____4. Duly executed adoption documents along with the adoptive parent’s photo ID _____5. Duly executed court custody documents along with the custodian’s photo ID _____6. Alien Card Homeowners: Non-homeowners:

◊ Submit Affidavit of Residence (part A) ◊ Submit Affidavit of Residence (parts B & C)

In addition both homeowners and non-homeowners must submit three proofs of residency, i.e.

LIPA bill Suffolk County Water bill Telephone bill Automobile registration (with new address) Driver’s license with new address (can be used as a photo ID) Other utility bill Bank Statement Official correspondence from Federal, State, or local government

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Part A

WEST BABYLON UNION FREE SCHOOL DISTRICT School: ____________________________________ Date: ________________________ Student’s Name: ___________________________ Grade: _______________________

Proof of Residency

Homeowner: Please submit this notarized affidavit and a copy of one of the following: 1. ◊ Real Estate Closing Statement ◊ Homeless 2. ◊ House Deed Complete attachment 3. ◊ Homeowner’s Insurance Policy 4. ◊ Current Tax Bill STATE OF NEW YORK AFFIDAVIT OF RESIDENCE FOR PARENT/HOMEOWNER COUNTY OF SUFFOLK ________________________________________________being duly sworn deposes and says: I am the parent/guardian of ___________________________________; that my permanent legal residence is ______________________________________; that this is the student’s permanent legal residence which is within the boundaries of the West Babylon District. I understand that this affidavit is made under oath: that the statements contained are true; that the West Babylon Board of Education will rely thereon, and that any misstatements made could result in criminal (perjury) charges being brought against the person whose signature appears hereon. I will accept full financial responsibility for any and all tuition charges as determined solely at the discretion of the West Babylon Public Schools. I may be subject to potential civil as well as criminal prosecution. ______________________________________________________ Signature of Parent Taken and sworn to before me this __________day of _______________,20_______. _________________________________________ Notary Public

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Part B

WEST BABYLON UNION FREE SCHOOL DISTRICT School: ____________________________________ Date: ________________________ Student’s Name: ___________________________ Grade: _______________________

◊ Homeless

Complete attachment STATE OF NEW YORK AFFIDAVIT OF RESIDENCE FOR PARENT/NON-HOMEOWNER COUNTY OF SUFFOLK ________________________________________________being duly sworn deposes and says: I am the parent/guardian of ___________________________________; that my permanent legal residence is ______________________________________; that this is the student’s permanent legal residence which is within the boundaries of the West Babylon District. I understand that this affidavit is made under oath: that the statements contained are true; that the West Babylon Board of Education will rely thereon, and that any misstatements made could result in criminal (perjury) charges being brought against the person whose signature appears hereon. I will accept full financial responsibility for any and all tuition charges as determined solely at the discretion of the West Babylon Public Schools. I may be subject to potential civil as well as criminal prosecution. ______________________________________________________ Signature of Parent Taken and sworn to before me this __________day of _______________,20_______. _________________________________________ Notary Public

WEST BABYLON PUBLIC SCHOOLS AFFIDAVIT OF LANDLORD

PART C This is a legal document. The information provided by you will be used by the Board of Education to determine whether a pupil is entitled to a free education in this school district. Every question must be answered or the affidavit will not be considered. The information provided by you will be used by the Board of Education to determine whether a pupil is entitled to a free education in this school district. Landlord: Must provide a copy of one of the following:

1. House Deed 2. Homeowner’s Insurance Policy 3. Current Tax bill

STATE OF NEW YORK) COUNTY OF SUFFOLK) I, __________________________________________, of full age, being duly sworn upon his or her oath, according to law, deposes and says:

1. I am the owner of the property located at ___________________________________________in the West Babylon Union Free School District.

2. _________________________________________is a tenant and has been a tenant at the above premises since

________________________________. A true and complete copy of the tenant’s lease, if in written form, is attached hereto. In the event that the tenant does not have a written lease, the pertinent terms of said lease are as follows:

a. Circle one of the following: month to month / year to year Start Date: __________End Date: __________

b. Rental Amount : $ __________________per ____________________.

c. The names of the permissible tenants are as follows:

1._______________________________________ 4. ______________________________________ 2. _______________________________________ 5. ______________________________________ 3. _______________________________________ 6. ______________________________________

3. I am making this affidavit knowing that the West Babylon Board of Education will rely on same in determining whether _______________________________________________will be considered a pupil who is entitled to an education free of charge.

4. I understand and agree that if any of the statements made by me are willfully false that:

a. I will accept full financial responsibility for any and all tuition charges as determined solely at the discretion of the West Babylon Public Schools: and that

b. I may be subject to potential civil as well as criminal prosecution. ___________________________________________________ Landlord’s Signature Sworn and subscribed before me this _____________day of ___________________, 20____. _______________________________________________ Notary Public

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WEST BABYLON SCHOOLS 10 Farmingdale Road

West Babylon, New York 11704 (631) 376-7001

FAX: (631) 376-7019

Anthony Cacciola Superintendent of Schools

HEALTH AND SOCIAL HISTORY Date___________________ NAME_____________________________Grade_______DOB__________PLACE OF BIRTH________________ ADDRESS_____________________________________________PHONE#_______________________________ FATHER’S NAME_____________________________MOTHER’S NAME_______________________________ WORK#______________________________________WORK#________________________________________ HISTORY TAKEN BY:__________________________HISTORY GIVEN BY:____________________________

1. What is the child’s general health at present (persistent complaints, presently on medication, special diet, etc.)?

Name and number of pediatrician: ________________________________________________________

2. Has your child ever had any of the following? If so, give date.

Chicken pox_______________ Rheumatic Fever_________________ Tuberculosis_____________ German measles____________ Anemia________________________ Contact w/TBC___________ Measles___________________ Nephritis_______________________ Asthma_________________ Mumps___________________ Diabetes________________________ Allergies/Reactions_______ Pneumonia________________ Epilepsy________________________ Ear Conditions___________ Heart Disease______________ Operations______________________ Serious Injuries___________ Transfusions_______________ Mononucleosis___________________ Hospitalizations__________ Strep Throat_______________ Falls/Head Injuries________________ Hepatitis_______________ Other________________________________________________________________________________ A space is provided below for additional information concerning conditions checked. ____________________________________________________________________________________

3. Does the child have: Date of Last Screening Medical Follow-Up

Motor Impairment? __________________ _________________ Visual Impairment? __________________ _________________

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Speech Impairment? __________________ _________________ Hearing Impairment? __________________ _________________ 4. Is your child physically able to participate in the physical education program?

Yes ________ No __________ If no, explain: _______________________________________________________________________ ___________________________________________________________________________________

5. Education History (Programs, Schools Attended)

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

6. Any Other Relevant Information:

a) Dental Screening:________________________________________________________________ b) Any Other Screening:_____________________________________________________________

7. Family History

a) Please note any complications you may have experienced with your pregnancy and/or delivery___ _____________________________________________________________________________

b) Was your child hospitalized at birth for any reason? _____________________________________________________________________________ c) Siblings: Name and age:__________________________________________________________ __________________________________________________________ Was your child hospitalized at birth for any reason?

_____________________________________________________________________________

c) Siblings: Name and age:_____________________________________________________________________________

d) Please note any others in the home:__________________________________________________

8. Please Attach M.D. Verified Immunization Record.

_________________________________

Parent/Guardian Signature

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WEST BABYLON SCHOOLS Student Registration Form – Racial and Ethnic Categories

Student’s Name______________________________ School______________________ (please print) (please print) The state and federal governments require school districts to report information regarding students’ primary language, primary language spoken by parents, students’ racial/ethnic group and immigrant status. Please complete the items below so we may have accurate information. Ethnic Categories (definitions supplied by New York State): [Check Only One] ___ Hispanic/Latino ___ Not Hispanic/Latino Racial Categories (definitions supplied by New York State): [Choose One or More, regardless of Ethnicity] ___ American Indian or Alaskan Native: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. ___ Asian: 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. ___ Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. ___ Black or African American: A person having origins in any of the black racial groups of Africa. ___ White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. Language: Primary language spoken by student at home: ____________________________________ Other languages spoken by student: __________________________________________ Primary language spoken by parents: _________________________________________ Immigration Information Country child was born in: _________________________________________________ Is the child a citizen of the United States? _____________________________________ If not, citizen of what country? ______________________________________________ Please provide the date child entered the U.S. __________________________________ What country did child live in prior to the U.S.__________________________________ Name of person completing this form: ________________________________________ Relationship to student: ___________________________________________________

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WEST BABYLON SCHOOLS West Babylon, NY 11704

NEW YORK STATE PUBLIC HEALTH LAW ARTICLE 21, SECTION 2164 AND AMENDMENTS

UNDER SECTION 2164 OF THE NEW YORK PUBLIC HEALTH LAW, AS OF SEPTEMBER 1998, THE MINIMUM REQUIREMENTS FOR SCHOOL ATTENDANCE INCLUDE: ___________ 3 DOSES DPT ___________ 1 VARIVAX VACCINE ___________ 3 DOSES OPV ___________ 3 DOSES HEPATITIS B ___________ 1 DOSE HIB ___________ 2 DOSES MMR* *(1 AFTER AGE 12 MONTHS; 1 BETWEEN AGE 4 AND ADMISSION TO KINDERGARTEN) EXCEPTIONS ARE TO BE MADE ONLY UPON (1) RECEIPT OF A PHYSICIAN’S STATEMENT THAT SUCH IMMUNIZATION MAY BE DETRIMENTAL TO A CHILD’S HEALTH, OR (2) RECEIPT OF A WRITTEN STATEMENT FROM THE PARENTS OR GUARDIAN CERTIFYING THAT THEIR RELIGIOUS BELIEFS PRECLUDE THE USE OF IMMUNIZATION.

COMPULSORY IMMUNIZATION LAW

THIS IS TO CERTIFY THAT: ___________________________________ _________________________ (CHILD’S NAME) (DATE OF BIRTH) ___________________________________ (ADDRESS) ___________________________________ _________________________ (SCHOOL) (GRADE) HAS BEEN IMMUNIZED AGAINST: DIPHTHERIA (DPT) 1. _________ 2. _________ 3. _________ BOOSTERS: 1. _________ 2. ________ MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MO./DAY/YR.

POLIOMYELITIS 1. _________ 2. _________ 3. _________ BOOSTERS: 1. _________ 2. ________ (LIVE-SABIN) MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MO./DAY/YR.

MEASLES (LIVE) 1. _________ 2. _________ HEPATITIS B: 1. _________ 2. ________ 3._________ MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. MUMPS 1. _________ 2. _________ RUBELLA 1. _________ 2. _________ MO./DAY/YR. MO./DAY/YR. . MO./DAY/YR. MO./DAY/YR. HIB: 1. _________ VARIVAX 1. __________ BOOSTER: __________ MO./DAY/YR. MO./DAY/YR. MO./DAY/YR. TUBERCULIN TINE TEST: ________ ________ or Risk Assessment conducted by physician- no testing necessary ______

MO./DAY/YR. RESULTS (initial) ____________________________________________ _______________ SIGNATURE OF PHYSICIAN OR NAME OF CLINIC DATE ________________________________________ _______________ SIGNATURE OF PARENT OR GUARDIAN DATE

NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and

triennially for the Committee on Special Education (CSE).

This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school medical director. Rev. 10/3/07

HEALTH APPRAISAL FORM

Name: Date of Birth:

School: Gender: M F Grade:

IMMUNIZATIONS / HEALTH HISTORY Immunization record attached Sickle Cell Screen: Positive Negative Not done Date: No immunizations given today PPD: Positive Negative Not done Date: Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done Date:

Dental Referral Yes No Not done Date:

Significant Medical/Surgical History: See attached

Specify current diseases: Asthma Diabetes: Type 1 Type 2 Hyperlipidemia Hypertension Other:

Allergies: LIFE THREATENING Food: Insect: Other: Seasonal Medication:

PHYSICAL EXAM Height: _______________ Weight: _______________ Blood Pressure: _______________ Date of Exam: Referral Body Mass Index: ____ ____ . ____ Vision - without glasses/contact lenses

R L

Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L

less than 5th 5th through 49th 50th through 84th Vision - Near Point R L

85th through 94th 95th through 98th 99th and higher Hearing Pass 20 db sc both ears or: R L

EXAM ENTIRELY NORMAL Tanner: I. II. III. IV. V. Scoliosis: Negative Positive:

Specify any abnormality (use reverse of form if needed):

MEDICATIONS Medications (list all): None Additional medications listed on reverse of form

Name: ____________________________________________________ Dosage/Time: _________________________________________________

Name: ____________________________________________________ Dosage/Time: _________________________________________________

If AM dose is missed at home: ________________________________________________________________________________________________

I assess this student to be self-directed Yes No Student may self carry and self administer medication Yes No Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency

sheltering is necessary at school or if the morning medication has not been given. PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:

___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball. ___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.

Specify medical accommodations needed for school: None

Known or suspected disability: Please monitor

Restrictions: Please monitor

Protective equipment required: Athletic Cup Sport goggles/impact resistant eyewear Other: (Stamp below)

Provider’s Signature: Phone:

Provider’s Name/Address: Fax:

Parent Signature: Date:

West Babylon School District Internet Use Agreement

I understand and will abide by the Internet and Acceptable Use policy (JFCI) and “The Attorney General’s Bill of Rights and Responsibilities for Student Internet Users” (see attached). I further understand that any violation of the regulations above is unethical and may constitute a criminal offense. Should I commit a violation, my access privileges may be revoked, and school disciplinary actions and/or appropriate legal action, may be taken. Student’s Name (please print):_____________________________________________________ Student’s Grade Level:___________________________________________________________ Student’s Building:______________________________________________________________ Student’s Signature:________________________________________Date:_________________ (If you are under the age of 18, a parent or guardian must also read and sign this agreement) PARENT OR GUARDIAN As the parent or guardian of this student, I have read the Internet and Acceptable Use Agreement. I understand that this access is designed for educational purposes. BOCES and the West Babylon School District, to the best of their ability, have taken precautions to eliminate controversial material. However, I also recognize it is impossible for West Babylon School District to restrict access to all controversial materials and I will not hold it responsible for materials my child may acquire on the network. Further, I accept full responsibility for supervision if and when my child’s use is not in a school setting. *I hereby give permission to the West Babylon School District to allow my child to gain access to the Internet and the district network system for the time he/she is in the school building (grades K-5; grades 6-8; grades 9-12) and that the information contained on this form is correct. If this form is not on file with the school building, I understand that my child will be denied access to the Internet in the school. Parent/Guardian’s Name (please print):_____________________________________________ Address: _____________________________________________________________________ Telephone (Home): ________________________ (Business): ___________________________ Signature: ______________________________________________ Date: _________________ 05-06/Forms/Registration/Internet Use

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AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

DATE: ________________________________________________________ STUDENT: ________________________________________________________ Last Name First Name DATE OF BIRTH: ________________________________________________________ GRADE : ________________________________________________________ Authorization is granted by the undersigned for release of all official records, files and data related to the above named student. Records are to be released to West Babylon Schools for the purpose of educational planning. Records should be forwarded to the above address. Release is authorized for all information and records that are intended for use in planning, evaluation and measurement of progress for educational purposes, including:

• academic records/academic work completed/portfolios/Science Labs • transcripts • level of achievement (grades, test scores, report cards, progress reports) • attendance data • disciplinary records (records transfer required under Section 3214 of Education Law) • health records, immunization records, medical records • results of medical evaluations including neurological and psychological evaluations • psychological tests, reports, updates • CSE records • I.E.P. and/or accommodation plans • school histories, family background information • related service evaluations (i.e., service therapy, occupational therapy, physical therapy, etc.)

Records are to be released by: Name of school/district or other organization________________________________________________________ Address______________________________________________________________________________________ Authorization is granted by: _____________________________________________________________________ I request the release of records as indicated above and attest to having the legal right to authorize this release of records. Signature _________________________________________________________ Name(Print) _________________________________________________________ Relationship _________________________________________________________ Address _________________________________________________________ Phone Number _________________________________________________________ :tr 01/05/06-05-06/Forms

WEST BABYLON SCHOOLS 10 Farmingdale Road

West Babylon, New York 11704

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Affidavit of Custody

Date: ______________________

I/We ____________________________________________________________, (Parent/Guardian Name, in the case of two parents, both names must be written) residing at _______________________________________________ ____________________

(Address) (Phone)

Hereby give full custody and control of _________________________________ to ____________________________________ residing at (Student Name) (Name)

___________________________________, _______________________ who shall have full (Address) (Phone)

authority for all custodial, educational, financial and medical matters. The student named above shall reside full time with _____________________________________. I understand that Guardianship is not being established for the purpose of attempting to establish residency for the student in the West Babylon Union Free School District. I make this affidavit, under penalty of perjury, to induce the West Babylon UFSD to accept ____________________________________ as a resident of the district. (Student’ s Name) ________________________________________ Parent(s)/Guardian(s) Signature Sworn to before me This _______________day of _____________, 20____. ______________________________________________ Notary Memo05-06/registration packet/affidavit of custody-giving custody

WEST BABYLON SCHOOLS 10 Farmingdale Road

West Babylon, New York 11704

AFFIDAVIT OF CUSTODY

Date: ______________________

I(We) __________________________________________________ residing at _______________________________________ hereby accept full authority and responsibility for all custodial, educational, financial and medical matters for: _________________________________. He/She shall reside with me full time. (Student’s Name)

I make this affidavit, under penalty of perjury, to induce the West Babylon UFSD to accept _____________________________________ as a resident of the district. (Student’s Name)

My residence _____________________________________ is located within the (address)

West Babylon School District. I will not receive any payment for the care and custody of _____________________________, nor will I receive repayment directly or (Student’s Name) indirectly for any expenses incurred on behalf of ____________________________________. (Student’s Name)

_____________________________________ (Signature)

_____________________________________ (Phone)

Sworn to before me This ___________day of _______________,200____. ________________________________________ Notary 05-06/Forms/Registration/affidavitofcustody-acceptingcustody

Human Resources

10 Farmingdale Road West Babylon, NY 11704

Anthony Cacciola Dominick Palma, PhD. Superintendent Assistant Superintendent

Yiendhy Farrelly Executive Director of Human Resources

631-376-7010

NOTE TO SCHOOLS/LEAS: Please assist students and families filling out this form. Do not simply include this form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required to submit proof of residency and other required documents that may be part of the registration packet.

ENROLLMENT FORM - RESIDENCY QUESTIONNAIRE

Name of LEA:

Name of School:

Name of Student:

Last First Middle

Gender: � Male Date of Birth: / / Grade: ID#: � Female Month Day Year (preschool-12) (optional)

Address: Phone:

The answer you give below 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.

Where is the student currently living? (Please check one box.) In a shelter With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as “doubled-up”)

In a hotel/motel In a car, park, bus, train, or campsite Other temporary living situation (Please describe): In permanent housing

Print name of Parent, Guardian, or Signature of Parent, Guardian, or

Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth) Date If the student is NOT living in permanent housing, proof of residency and other documents normally needed for enrollment are not required and the student is to be immediately enrolled. After the student has been enrolled, the district/school must contact the previous district/school attended to request the student's educational records, including immunization records, and the enrolling district's LEA liaison must help the student get any other necessary documents or immunizations. NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a Designation Form is completed.

ATENCIÓN ESCUELAS Y DISTRITOS: Ofrezca asistencia a los estudiantes y familias para completar este formulario. No incluya este formulario en el paquete de inscripción sin advertencias apropiadas. Por ejemplo, tendrá que cambiar partes del paquete de inscripción que requieren que se entreguen prueba de inscripción antes de matricular. Estudiantes elegibles según el Acto de McKinney-Vento, no necesitan entregar prueba de residencia y otros documentos normalmente requeridos antes de matricular.

FORMULARIO DE INSCRIPCIÓN – CUESTIONARIO DE RESIDENCIA

Nombre del Distrito Escolar: _________________________________________________________________

Nombre de la Escuela: _____________________________________________________________________

Nombre del Estudiante: _____________________________________________________________________ Apellido Primer Nombre Segundo Nombre

Género: Hombre Fecha de Nacimiento: _____ / _____ / ______ Grado:______ ID#: _______ Mujer Mes Dia Año (jardín (opciónal)

de infantes – 12)

Dirección: _______________________________________________ Teléfono: _____________________

Su respuesta abajo permitirá al distrito escolar definir los servicios que puede aprovechar su hijo/hija según el Acto de McKinney-Vento. Los estudiantes elegibles tienen derecho a la inscripción inmediata en la escuela, aun si ellos no tienen los documentos necesarios tales como: prueba de residencia, documentos escolares, documentos de inmunización, o partida de nacimiento. Los estudiantes elegibles según el Acto de McKinney-Vento tienen además derecho al transporte gratuito y otros servicios que ofrece el distrito escolar.

¿Donde está el estudiante viviendo actualmente? (Por favor marque una caja.)

En un refugio Con otra familia o otra persona debido a la pérdida del hogar o a dificultades económicas En un hotel/motel En un carro, parque, autobús, tren, o camping Otra vivienda temporal (Por favor describa):

__________________________________________________________________________ En un hogar permanente

________________________________________ _______________________________________

Nombre de Padre, Guardián, o Firma de Padre, Guardián, o Estudiante (para jóvenes sin acompañamiento) Estudiante (para jóvenes sin acompañamiento)

____________________________ Fecha Si el estudiante NO vive en un hogar permanente, no se requieren prueba de domicilio u otros documentos normalmente requeridos para inscripción y el estudiante debe ser matriculado inmediatamente. Después de que el estudiante sea matriculado, el distrito o la escuela debe pedir los documentos escolares, incluyendo los documentos de inmunización, al distrito o la escuela anterior. El enlace del distrito debe ayudar al estudiante conseguir cualquier otro documento necesario o inmunización. ATENCIÓN ESCUELAS Y DISTRITOS: Si el estudiante NO vive en un hogar permanente, favor de asegúrese que una Formulario de Designación sea completado.

INSTRUCTIONS FOR COMPLETING THE ENROLLMENT FORM – RESIDENCY QUESTIONNAIRE

Purpose of the Enrollment Form - Residency Questionnaire All LEAs are required to identify students experiencing homelessness. Additionally, all LEAs that receive Title I funds must ask enrolling students about their housing status. SED encourages all LEAs regardless of whether they receive Title I funds to do the same. To collect this information, LEAs may:

1. Use the Model Enrollment Form - Residency Questionnaire attached here, 2. Update/modify the Model Enrollment Form - Residency Questionnaire to address the needs of the LEA,

or 3. Incorporate the housing status question from the Model Enrollment Form - Residency Questionnaire into

the LEA’s Enrollment Form or other documents already used by the LEA during the enrollment process. If an LEA elects the third option and incorporates the housing status question into the LEA’s Enrollment Form, the LEA should take steps to ensure that a student’s housing status does not become a part of the student’s permanent record, because of the sensitive nature of this information. Please see the section titled “Confidentiality” (below) for information about how and when housing information may be shared within the LEA.

Who should fill out the Enrollment Form - Residency Questionnaire? A Enrollment Form - Residency Questionnaire should be filled out for all students enrolling in school and for all students who have a change of address in grades preschool-12. Preschool includes any LEA program for 3-5 year olds, such as pre-k, Head Start, or Even Start. The Form - Questionnaire should be completed by the student’s parent, person in parental relation, or in the case of an unaccompanied youth, by the student directly.

Confidentiality Student housing information should be kept confidential to the maximum extent possible. This information should only be shared with LEA/school staff members who need information about housing status to ensure that the student’s educational needs are met. To this end, LEAs may share a student’s completed Enrollment Form - Residency Questionnaire with LEA personnel such as:

1. the LEA liaison, 2. the registrar, 3. the student’s teachers, and/or guidance counselor, and 4. the LEA staff member responsible for reporting data to SED

However, this information should only be shared with the above staff members to the extent that it will enable them to better meet the educational needs of the student in question and to fulfill reporting requirements mandated by SED. Other than the above uses, housing information should be kept confidential and generally should not be shared with other LEA/school personnel due to its sensitive nature and the stigma attached to being labeled homeless. LEAs are also encouraged to seek out ways of preventing Enrollment Form - Residency Questionnaires and housing information from becoming a part of a student’s permanent record.

Discussing the Enrollment Form - Residency Questionnaire with Students and Families

In reviewing the Enrollment Form - Residency Questionnaire with parents, persons in parental relation, and unaccompanied youth, LEAs should emphasize that the purpose of gathering the information is to ensure that students in temporary housing arrangements are provided with the rights and services to which they are entitled under the McKinney-Vento Act. These rights and services include:

1. The right to stay in the same school the student had been attending before losing his/her housing or the last school attended (both known as the school of origin),

2. The right to immediate enrollment for students who decide to transfer schools, even if the student does not have all of the documents normally for enrollment,

3. Transportation services if the student continues to attend the school of origin, 4. Categorical eligibility for Title I services if offered in the LEA, 5. Categorical eligibility for free meals if offered in the LEA, and 6. Access to services provided with McKinney-Vento funds if available in the LEA.

The LEA should also ensure that the parent, person in parental relation, unaccompanied youth is aware that the student’s housing status will kept confidential and will only be shared with those LEA 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 in the LEA.

LEAs are advised to explain to parents that if a parent claims that her/her child is living in temporary housing, and the LEA wishes to conduct an investigation to verify this information, the LEA may conduct a home visit. However LEAs cannot contact a landlord or building superintendent to verify a student’s housing status. Contacting a landlord or building superintendent may be a violation of FERPA, a federal law, and may put the family at risk of losing its housing. If the student is living in a doubled up situation, it may also lead to loss of housing for the primary tenants.

If the Parent, Person in Parental Relation, or Unaccompanied Youth Declines to Fill Out the Enrollment Form - Residency Questionnaire If the parent, person in parental relation, or unaccompanied youth declines to complete the Enrollment Form - Residency Questionnaire, the LEA should note on the form that the parent, person in parental relation, or unaccompanied youth declined to provide the information requested.

Completing the Form If a parent, person in parental relation, or unaccompanied youth enrolling in school indicates that a student is living in one of the five temporary housing arrangements, the school may not require proof to verify where the student is living before enrolling the student. The five temporary housing arrangements are listed below:

1. In a shelter, 2. With another family or other person (sometimes referred to as “doubled-up”), 3. In a hotel/motel, 4. In a car, park, bus, train, or campsite, or 5. Other temporary living situation.

After the student is enrolled and attending classes, the school or LEA is permitted to verify the student’s housing arrangements. However, the student must first be enrolled in school. Again, LEAs cannot not contact a landlord or building superintendent to verify a student’s housing status. (See above for more information.)

Definitions of Temporary Housing Arrangements

“With another family or other person” (also referred to as “doubled-up”)” LEAs should be aware that students who are sharing the housing of others are eligible for services under the McKinney-Vento Act and State law, if sharing housing is due to loss of housing, economic hardship, or a similar reason.

“Other temporary living situation”

In addition to the four examples of temporary housing, students who lack a “fixed, adequate, and regular” nighttime residence are also covered as homeless under the McKinney-Vento Act and State law. This may include unaccompanied youth who have fled their homes or were forced to leave their homes and who do not otherwise meet the definition of “doubled-up.”

“In permanent housing”

Permanent housing means that the student’s living arrangements are “fixed, regular, and adequate.”

Next Steps for LEAs with Students Living in Temporary Housing Arrangements If the parent, person in parental relation, or unaccompanied youth indicates that a student is living in temporary housing, the LEA must complete a Designation Form. If the LEA believes additional information is needed before reaching a final decision on the student’s eligibility under McKinney-Vento, enrollment should not be delayed and a Designation Form should still be filled out. For more information about determining eligibility see the National Center on Homeless Education’s Determining Eligibility Brief, available at: www.serve.org/nche/downloads/briefs/det_elig.pdf

If a student who is identified as homeless was last permanently housed in a different school district, the district of attendance/local district will be eligible for tuition reimbursement from SED for the cost of educating the student. School districts should complete a STAC-202 form if eligible for tuition reimbursement. For more information about STAC-202 forms contact the STAC Office at 518-474-7116 or NYS-TEACHS at 800-388-2014.