11 Foxcroft Drive
Livingston, NJ 07039
Phone: 973-535-8000
FAX: 973-535-1254
www.livingston.org
Kindergarten Registration Process
Only a parent or legal guardian may register a student in the Livingston School District. Registration Packets are available from the Administrative Offices or may be downloaded from our website. Completed registration packets can be returned to the Board of Education office by contacting Amy Ennis, Registrar, to set up an appointment. Amy Ennis may be reached at (973) 535-8000 Ext. 8002.
To process a new student registration, please complete and supply the following documentation for your student:
Original Birth Certificate
Student Registration Form LPS-REGISTRATION-01K
Parent/Guardian Information Form LPS-REGISTRATION-02K
NJ SMART Information Form LPS-REGISTRATION-03K
Pre-School Information Form LPS-REGISTRATION-04K
The following Health Services information should be brought to the Registrar. However, if they are not yet completed, all forms must be provided no later than June 1, 2015. If your child was born between June 2 and October 1, please provide the most up to date immunization records by June 1, 2015 and provide the completed Student Medical Examination Form as soon as possible. No student will be admitted to any school in our district without evidence of having been immunized.
Student Medical Examination/Immunization Record Form LPS-REGISTRATION-HEALTH-01K
Dental Form LPS-REGISTRATION-HEALTH-02K
Confidential Medical Information Form
Mantoux Tuberculin Notification Form LPS-REGISTRATION-HEALTH-03K (if applicable)
Please note that additional documentation is required for the following circumstances:
If Parents/Guardians live at more than one residence, regardless of which parent has legal custody, court documentation of the custody agreement must be supplied.
If Legal Guardian, court documentation of guardianship is required.
If Guardian for a student with parents who do not reside in Livingston, complete forms LPS-REGISTRATION-AFFIANT, Affidavit of Domiciliary and Affidavit of Non-Resident Parent/Guardian.
Revised 4/2014 LPS-KINDERGARTEN-REGISTRATION
11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Depending upon your circumstances, the parent/guardian should supply the documents listed below*:
Proof of Ownership for Student Living with Parent/Guardian who is a Livingston Homeowner:
Original deed or tax bill PLUS
Original of current month or one month prior’s utility bill
Proof of Tenancy for Student Living with Parent/Guardian who is a Livingston Renter:
Copy of lease PLUS
Owner/Landlord Affidavit Form LPS-REGISTRATION-05K PLUS
Original of current month or one month prior’s utility bill
Proof that Student and Parent/Guardian are Living with Other Family/Friend who is a Livingston Homeowner:
Documentation from Homeowner:
Letter from homeowner explaining living arrangements PLUS
Original homeowner’s deed or tax bill PLUS
Original current month or one month prior’s utility bill
Documentation from Parent/Guardian of student:
Bank statement PLUS
Bill or pay stub
Proof that Student and Parent/Guardian Living with Other Family/Friend who is a Livingston Renter:
Documentation from Homeowner:
Letter from homeowner explaining living arrangements PLUS
Completed Owner/Landlord Affidavit Form LPS-REGISTRATION-05K PLUS
Renter’s copy of lease PLUS
Original current month or one month prior’s utility bill
Documentation from Parent/Guardian of student:
Bank statement PLUS
Bill or pay stub
*PLEASE NOTE: If parent/guardian is unable to provide any of the documents listed above, please contact Amy Ennis, Registrar at 973-535-8000, x8002.
NOTICE OF ELIGIBILITY: For the current school year, a child is eligible for entrance into kindergarten at the start of the regular school year if he/she has reached five (5) years of age on or before October 1st, and a child is eligible for entrance into first grade at the start of the regular school year if he/she has reached six (6) years of age on or before October 1st. For additional information regarding Entrance Age, please refer to our Policy #5112 available under Policies on the district website.
Revised 4/2014 LPS-KINDERGARTEN-REGISTRATION
11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Kindergarten Registration
Last Name / First NameMiddle Name / Nickname
Date of Birth / Female / Male
Home Address / Apt. #
City / State / Zip
Home Phone / Cell Phone
Previous Address:
Home Address / Apt. #
City / State / Zip
Language(s), other than English, spoken at home:
Will your child require support in learning the English Language? / Yes / No
Check if your child currently has/previously had an IEP or 504 plan: / IEP / 504 Plan
Please provide explanation/documentation:
The information above is true and correct. Fraudulent statements will be prosecuted to the full extent of the law.
Signature of Registering Parent/Guardian / Date
The following documentation is required before your child may be admitted to our school. No child shall be admitted without proof of current complete required immunizations. Initial determination of eligibility is subject to thorough review and evaluation. Admission later found ineligible may be subject to assessment of tuition or removal from school.
OFFICE USE ONLY
Eligible for bussing? / Yes / No / Home School
Health Records / Immunizations / Health Profile / Dental
Proof of Ownership/Tenancy (3) / Deed / Lease / Utility Bills / Property Tax Bills
Other
Lease Expiration Date / Lease Affidavit
Birth Certificate / Country / City/State
Guardianship/Custody Papers/Court Orders/Affidavit
Additional Documents Needed
Transcripts
Student ID: / Date of Registration:
Revised 4/2014 LPS-REGISTRATION-01K
11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Kindergarten Registration
(Parent/Guardian Information)
Parent/Guardian 1 (will be used as primary contact)
First Name / Last Name
Relationship to Student
Address / City / State / Zip
Own / Rent (complete Form LPS-REGISTRATION-05) / Other:
Home Phone / Primary Email
Work Phone / Other Email
Cell Phone / Cell Phone Provider (optional)
Parent/Guardian 2
First Name / Last Name
Relationship to Student
Address / City / State / Zip
Own / Rent (complete form LPS-REGISTRATION-05) / Other:
Home Phone / Primary Email
Work Phone / Other Email
Cell Phone / Cell Phone Provider (optional)
*Student Lives With: / Parent/Guardian 1 and 2 / Parent/Guardian 1 / Parent/Guardian 2
Other (please explain):
*If a custodial agreement exists, custody papers or notarized statement from the custodial parent must be provided to allow for a second reporting account for the student (i.e., report cards, messages from administrators, etc.).
Siblings/Other Children Living in the Household
Full Name / Date of Birth / Gender / School / Grade
Female / Male
Female / Male
Female / Male
Female / Male
The information above is true and correct. Fraudulent statements will be prosecuted to the full extent of the law.
Signature of Registering Parent/Guardian / Date
Revised 4/2014 LPS-REGISTRATION-02K
11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Kindergarten Registration
NJ SMART Information
New Jersey Standards Measurement and Resource for Teaching
(as required by the State of New Jersey)
Date of Birth / Female / Male
Date of Entry Into First US School (if applicable):
(To be completed by the district.) / (To be completed by district if not a transfer student.)
Student ID / State ID
Ethnic Group (check all that apply)
White / Black / Hispanic / American Indian/Alaskan
Asian / Hawaiian Native/Other Pacific Islander
Language
Primary Language Spoken / Other Language(s) Spoken
Health Information
Physician’s Name
Address / City / State / Zip
Phone / FAX
Date of Last Exam: / Date of Last Lead Test:
Does student have
health insurance? / Yes (please specify provider):
No
If no, NJ FamilyCare provides free or low cost health insurance for uninsured children and certain low income parents. For more information call 800-701-0710 or visit www.njfamilycare.org to apply online.
I hereby give Livingston Public Schools permission to release my name and address to the NJ FamilyCare Program to contact me about health insurance.
Written consent required pursuant to 20 U.S.C. § 1232g(b)(1) and 34 C.F.R. 98.30(b).
Signature: / Printed Name: / Date:
For additional information regarding NJ SMART, visit http://www.state.nj.us/education/njsmart.
Revised 4/2014 LPS-REGISTRATION-03K
Livingston Public Schools11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Kindergarten Registration
Current Pre-School Information Form
Student InformationLast Name / First Name / Middle Name
Address / City / State / Zip
Home Phone / Date of Birth / Female / Male
Previous School
Name of School / Public / Private
Street Address
City / State / Zip
School Phone Number / School FAX Number
Last Day Student Attended
I hereby give permission for release of the above records and for the school district to contact my child’s former district for further information. In addition to the release of the above records to which you consent, the prior District will be releasing the following mandated records for which your consent is not required: transcript of grades, health records, attendance records, child study team records and disciplinary records pursuant to N.J.A.C. 6:3-6.5.
Signature of Parent/Guardian / Date
Office Use Only
Send Record Information to:
Requested By: / Received By:
Date Requested: / Date Received:
Revised 4/2014 LPS-REGISTRATION-04K
11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Kindergarten Registration
Owner/Landlord Affidavit
(for those who rent their home)
Last Name / First Name
Address / Apt. #
City / State / Zip
Home Phone / Alternate Phone
Tenant Information
Last Name / First Name
Address / Apt. #
City / State / Zip
Home Phone / Alternate Phone
Leasing Information
When did tenant(s) move in? / Relation to Renter: / None
How long is the lease agreement? / Family Member
Friend
Type of rental agreement: / Yearly / Month-to-Month / Rent-to-Own
List Names of all Persons Living in the Above-Named Residence
1. / 6.
2. / 7.
3. / 8.
4. / 9.
5. / 10.
If applicable, please read and check:
I am aware that said leasee has additional family members residing in subject property.
I attest that to the best of my knowledge the information is true and correct, and I am aware that fraudulent statements or claims may be prosecuted to the full extent of the law.
Sworn and subscribed before me
this / day of / .
Signature of Owner/Landlord
(A Notary Public of New Jersey) / Date
Revised 4/2014 LPS-REGISTRATION-05K
Livingston, NJ 07039
Phone: 973-535-8000
FAX: 973-535-1254
www.livingston.org
Kindergarten Registration Process
Health Services Information
All new students entering the Township of Livingston Public Schools must have the following health-related documentation on record prior to his/her first day of school:
Pursuant to Title 8-Chapter 57, New Jersey Department of Health and Regulations require that all New Jersey pupils be immunized against Diphtheria, Tetanus, Whooping Cough (Pertussis), Polio, Measles (Rubeola), German Measles (Rubella) and Mumps. No pupil will be admitted to any school in our district without evidence of having been immunized by the following agents and a Certificate of Immunization History (included on Form LPS-REGISTRATION-HEALTH-01K) completed and signed by a licensed health care provider:
Diphtheria Toxoid
Pertussis Vaccine
Tetanus Toxoid
Live Poliomyelitis Vaccine – Trivalent
Live attenuated Measles Virus Vaccine and Measles Booster Vaccine
Live Rubella Virus Vaccine
Live Mumps Vaccine
HIB Vaccine (required for all incoming kindergarten and pre-school students)
Hepatitis B Vaccine
Varicella Vaccine
Pursuant to N.J.A.C. 6A:16-2.2, upon entering the school district each child must have an up-to-date physical examination (Form LPS-REGISTRATION-HEALTH-01K). This examination must have been completed by a licensed health care provider no more than 365 days prior to entering school. Please return this form to the school nurse. Failure to submit Form LPS-REGISTRATION-HEALTH-01K could result in your child’s exclusion from school.
Student Medical Examination/Immunization Record Form LPS-REGISTRATION-HEALTH-01K
Dental Form LPS-REGISTRATION-HEALTH-02K
Confidential Medical Information Form
Mantoux Tuberculin Notification Form LPS-REGISTRATION-HEALTH-03K (if applicable)
*The Health Services Information packet should be brought to the Registrar. However, if they are not yet completed, all forms must be provided no later than June 1, 2015. If your child was born between June 1 and October 1, please provide the most up to date immunization records by June 1, 2015 and provide the completed Student Medical Examination Form as soon as possible.
Revised 4/2014 LPS-REGISTRATION-HEALTH-K
11 Foxcroft Drive
Livingston, NJ 07039 / 973-535-8000
www.livingston.org
Kindergarten Registration
Student Medical Examination
(to be completed by a licensed health provider)
Student Name: / Date of Birth: / Female MaleHome Address:
School: / Grade:
Growth and Development: / Normal / Premature / Term
Complications
Early illness or injury
Systems Review:
Height / Weight / BMI / Blood Pressure
Vision: / R / L / B / Glasses/Contacts
Audio: / R / L / EENT / Speech
Integument / Head & Neck / Lymphatic
Respiratory / Cardiovascular / Abdomen
Gastrointestinal / Genitourinary / Urinalysis
Musculoskeletal / Hernia / Scoliosis
Nervous / Emotional Symptoms / Nutrition
Neurological/Psychological:
General Assessment:
Remarks (Please list any special needs and/or medication required.):
Medical History:
Year / Year / Year / Year
Allergies / Asthma / Ottis Media / Operations/Injuries
Drug Sensitivities / Chicken Pox / Rheumatic Fever
Lyme Disease / Seizure Disorder / Strep Infections / Hospitalizations
Hepatitis / Diabetes / Mononucleosis
Neuromuscular Disease / Heart Disease / Other / Congenital Defects
(PLEASE USE PAGE 2 FOR IMMUNIZATION HISTORY.)
Revised 6/2015 LPS-REGISTRATION-HEALTH-01K
Student Name:Immunization History:
DTaP: / 1. / 2. / 3. / 4. / 5.
mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy / Booster
Tdap:
(for students born after January 1997 and students entering Grade 6)
Booster
Polio / IPV: / 1. / 2. / 3. / 4. / 5.
mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy
OPV: / 1. / 2. / 3. / 4. / 5.
mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy
MMR: / 1. / 2. / 3.
mm/dd/yy / mm/dd/yy / mm/dd/yy
Measles: / 1. / 2.
mm/dd/yy / mm/dd/yy
Mumps: / 1. / 2.
mm/dd/yy / mm/dd/yy
Rubella: / 1. / 2.
mm/dd/yy / mm/dd/yy
HIB Vaccine: / 1. / 2. / 3. / 4. / 5.
mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy
Hepatitis A Vaccine: / 1. / 2.
mm/dd/yy / mm/dd/yy
Hepatitis B Vaccine: / 1. / 2. / 3.
mm/dd/yy / mm/dd/yy / mm/dd/yy
PPD Mantoux: / Date Tested: / Date Read: / Results:
Lead Test: / Date Tested: / Lead Level:
Varicella Zoster: / 1. / 2.
mm/dd/yy / mm/dd/yy
Influenza Vaccine:
(mandatory for pre-school students) / 1. / 2. / 3. / 4.
mm/dd/yy / mm/dd/yy / mm/dd/yy / mm/dd/yy
Pneumonoccal Vaccine:
(mandatory for pre-school students) / 1.
mm/dd/yy
Meningococcal Vaccine:
(mandatory for incoming Grade 6 students) / 1. / 2. / 3.
mm/dd/yy / mm/dd/yy / mm/dd/yy
Other (specify):
Date of Examination: / Physician’s Signature:
Revised 6/2015 LPS-REGISTRATION-HEALTH-01K