EAST LYME PUBLIC SCHOOLS: 2017-2018 PUPIL INFORMATION FORM

Student Information
Last: / First: / Middle:
Birth Date: / ☐Female ☐Male / Nickname:
Student lives with:☐Both Parent ☐Mother only ☐Father only☐Joint Shared Custody☐Other(describe)______
Custody Alert:
Legal documentation must be provided
Primary Household – Primary Parent(s)/Guardian(s) Living with Student
Street Address: / Town: / Zip Code:
Address should receive mailings? ☐Yes ☐No
Household Phone Number: ( )
Messenger Notification – Check all that apply Voice- ☐Emergency ☐Attendance ☐Behavior ☐General ☐Teacher
Parent/Guardian #1(living in this household)
☐Mrs. ☐Mr. ☐Ms. ☐Dr. / First and Last Name: / Birth Date: (Month/day only)
Legal relationship to student: ☐Parent ☐Foster Parent ☐Stepparent ☐Grandparent ☐Surrogate
Do you want to receive Messenger Notifications? ☐Yes ☐No / Access to student in Parent Portal ☐Yes ☐No(if yes, setup is needed)
Legal Guardian ☐Yes ☐No / US Citizen? ☐Yes ☐No / Employer:
Cell Phone: ( ) / Work Phone: ( )
Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Text-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher / Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance☐Behavior☐General☐Teacher
Text-☐Emergency ☐Attendance ☐Behavior ☐General ☐Teacher
Email: / 2nd Email:
Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher / Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Parent/Guardian #2 (living in this household) if applicable
☐Mrs. ☐Mr. ☐Ms. ☐Dr. / First and Last Name: / Birth Date: (Month/day only)
Legal relationship to student: ☐Parent ☐Foster Parent ☐Stepparent ☐Grandparent ☐Surrogate
Do you want to receive Messenger Notifications? ☐Yes ☐No / Access to student in Parent Portal ☐Yes ☐No(if yes, setup is needed)
Legal Guardian ☐Yes ☐No / US Citizen ☐Yes ☐No / Employer:
Cell Phone: ( ) / Work Phone: ( )
Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Text-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher / Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher
Text-☐Emergency ☐Attendance ☐Behavior ☐General ☐Teacher
Email: / 2nd Email:
Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher / Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Siblings Living with Student – List from Oldest to Youngest
First and Last Name / Birth Date / First and Last Name / Birth Date
1. / 4.
2. / 5.
3. / 6.
Secondary Household –Parent(s)/Guardian(s)
Street Address: / Town: / Zip Code:
Address should receive mailings? ☐Yes ☐No / Does student also reside at this address? ☐Yes ☐No
Household Phone Number: ( )
Messenger Notification – Check all that apply Voice- ☐Emergency ☐Attendance ☐Behavior ☐General ☐Teacher
Parent/Guardian #1(living in this household)
☐Mrs. ☐Mr. ☐Ms. ☐Dr. / First and Last Name: / Birth Date: (Month/day only)
Legal relationship to student: ☐Parent ☐Foster Parent ☐Stepparent ☐Grandparent ☐Surrogate
Do you want to receive Messenger Notifications? ☐Yes ☐No / Access to student in Parent Portal ☐Yes ☐No(if yes, setup is needed)
Legal Guardian ☐Yes ☐No / US Citizen? ☐Yes ☐No / Employer:
Cell Phone: ( ) / Work Phone: ( )
Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Text-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher / Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher
Text-☐Emergency ☐Attendance ☐Behavior ☐General ☐Teacher
Email: / 2nd Email:
Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher / Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Parent/Guardian #2(living in this household) if applicable
☐Mrs. ☐Mr. ☐Ms. ☐Dr. / First and Last Name: / Birth Date: (Month/day only)
Legal relationship to student: ☐Parent ☐Foster Parent ☐Stepparent ☐Grandparent ☐Surrogate
Do you want to receive Messenger Notifications? ☐Yes ☐No / Access to student in Parent Portal ☐Yes ☐No(if yes, setup is needed)
Legal Guardian ☐Yes ☐No / US Citizen? ☐Yes ☐No / Employer:
Cell Phone: ( ) / Work Phone: ( )
Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance☐Behavior☐General ☐Teacher
Text-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher / Messenger Notification – Check all that apply
Voice-☐Emergency☐Attendance ☐Behavior ☐General ☐Teacher
Text-☐Emergency ☐Attendance ☐Behavior ☐General ☐Teacher
Email: / 2nd Email:
Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher / Messenger Notification – Check all that apply
☐Emergency☐Attendance☐Behavior☐General ☐Teacher
*Messenger Notification System is used to provide timely communication to Parent/Guardian’s home, cell, work phone(s) and email(s). You will receive instructions on how to setup a parent portal account to review and update contact information and control the ways in which you are contacted.
Additional Emergency Contacts/ Authorized Pickup –
Individuals who will be available to pick up student in case of illness or emergency
Name: / Phone # / ☐Cell ☐Home ☐Work / ☐Emergency or Illness
☐Dismissal w/ note
Name: / Phone # / ☐Cell ☐Home ☐Work / ☐Emergency or Illness
☐Dismissal w/ note
Name: / Phone # / ☐Cell ☐Home ☐Work / ☐Emergency or Illness
☐Dismissal w/ note
Name: / Phone # / ☐Cell ☐Home ☐Work / ☐Emergency or Illness
☐Dismissal w/ note
Name: / Phone # / ☐Cell ☐Home ☐Work / ☐Emergency or Illness
☐Dismissal w/ note
Name: / Phone # / ☐Cell ☐Home ☐Work / ☐Emergency or Illness
☐Dismissal w/ note
State and Federal Reporting
Student’s Birth City: / Birth State: / Birth Country:
Student was born on a US Military Base ☐ / Name of Base: / Location:
If student was not born in the USA, please supply date of entry into U.S.:
If student was not born in the USA, please supply date of entry into U.S. school:
If student was not born in the USA, please supply date of entry into CT school:
Is student a U.S. Citizen? ☐Yes ☐No
What is the primary language spoken in the home, regardless of the language spoken by the student?
What is the language most often spoken by the student?
What is the language the student first acquired?
Please check one or more races that apply: ☐Asian ☐Black or African American ☐Native American Indian or Alaskan Native
☐Native Hawaiian or Other Pacific Islander ☐White
Ethnicity: Also, is the student Hispanic/Latino? ☐Yes ☐No
Homeless: ☐Not Homeless ☐Shelter ☐Double up ☐Unsheltered☐Hotel/Motel
Medical/Health Information
Does the student have health insurance? ☐Yes ☐No
Permission is given, if deemed necessary, to transport my child by ambulance to local hospital. ☐Yes ☐No
Physician’s Name: / Physician’s Phone Number:
Dentist’s Name: / Dentist’s Phone Number:
Kindergarten Registration Only
Did student attend Head-Start Program, licensed nursery school, licensed daycare center or public preschool? ☐Yes ☐No
If yes, please supply the following / Name______
Town/City______
State______
New Transfering Students Only
Previous Enrollment Information
School Name:
Address: City: State: Zip:
Last Day Attended: Grade Level:
Services received at previous school: ☐Birth to Three ☐Special Education ☐Speech ☐OT ☐PT ☐Counseling ☐Math Support
☐Reading Support ☐Writing Support ☐English Language Learner
Does the student have an active section 504 Plan? ☐Yes ☐No
Does the student have an active Individual Education Plan (IEP)? ☐Yes ☐No
Has the student ever attended East Lyme Public Schools? ☐Yes ☐No
If Yes, which school and when?

Parent/Guardian #1Signature: ______Date: ______