EASTCHESTER UNION FREE SCHOOL DISTRICT
550 White Plains Rd 2nd floor Eastchester, New York10709

AH______GV______

APPLICATION FOR ADMISSION TO DISTRICT SCHOOLS

To be completed by child’s parent or legal guardian in black ink.

This form must be completed in its entirety.

STUDENT DATA

Name of Child: (Last, First)______Gender: M  F 

  1. Date of Birth: ______City/State of Birth:______
  1. Country of Birth:______Date Entered US 1st Time:______
  1. Most Recent Date of Entry to U.S. Schools: ______Language Spoken at Home:______
  1. Which school and what grade does child wish to enter:______
  1. Ethnicity/Race (as required by Federal Law):Is this student (or are you) Hispanic/Latino? (choose only one) ___ No, not Hispanic/Latino ___ Yes, Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, Cuban, South or

Central American, or other Spanish culture or origin, regardless of race.)

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your student’s (or your) race to be.

What is the student’s (or your) race? (Choose one or more)

___American Indian or Alaska Native (a person having origins in any of the

original peoples of North and South America (including Central America), and

who maintains tribal affiliation or community attachment.)

___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.)

___Black or African American (A person having origins in any of the black racial

groups of Africa.)

___Native Hawaiian or other Pacific Islander (A person having origins in any of

theoriginal peoples of Hawaii, Guam, Samoa or other PacificIslands.)

___White (A person having origins in any of the original peoples of Europe, the

Middle East or North Africa.)

  1. Student lives with: ___ Both Parents___ Mother___ Father

___ Legal Guardian (s)___Other______

  1. Name of person(s) identified in #6:______

a)Present address of person(s)named above:______

______

b) Home Phone #:______Cell #:______

c) How many years there: ______d) Previous school district of resident: ______

e) Last previous address: ______

  1. All former addresses where child has lived:

StreetCity StateDateWith Whom

______

______

______

  1. All former schools child attended, in chronological order (most recent first):

SchoolDistrictCityStateDatesGrade

______

______

______

______

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.

  1. 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

  1. Address where child presently lives: ______
  1. Phone # where child presently lives: ______
  1. How long will the child live at this address:______

FAMILY DATA

  1. Is the child’s biological or adoptive mother living? ___ Yes ___ No
  1. Biological/Adoptive Mother’s Name: ______

a)Home Address:______

b)Home Telephone #:______Listed/Unlisted:______

c)Cell #:______Date of Birth: ______

d)Email Address: ______

e)Occupation: ______

f)Employer: ______

g)Address of Employment: ______

h)Work phone: ______

  1. Is the child’s biological or adoptive father living? ___ Yes ___ No
  1. Biological/Adoptive Father’s Name: ______

a) Home Address: ______b) Home Telephone #: ______Listed/Unlisted:______

c) Cell #:______Date of Birth: ______

d)Email Address: ______

e)Occupation: ______

f)Employer: ______

g)Address of Employment: ______

h)Work phone: ______

  1. If parent/guardian has any other children, please supply the following information:

NameAgeAddressSchoolGuardian

______

______

______

RESIDENCYCUSTODIAL DATA

  1. If moving into Eastchester District, please specify moving date: ______
  1. Please specify if you are: Buying: ______Leasing: ______Own:______, your home. If you are leasing, please specify the date your lease expires: ______
  1. Will the child be spending overnights, weekends, holidays or vacations elsewhere? __ Yes __ No If yes, please give complete details, use separate sheet if needed: ______

______

  1. Does either parent maintain another residence elsewhere? ___ Yes ___ No

a)Address: ______

b)Months per year spent at other residence: ______

c)Does either parent intend to remain at this address?

Mother: ______Father: ______

  1. Address where each parent is registered to vote:

Mother: ______Father: ______

  1. Do the child’s biological parents own real estate property in the Eastchester school district? If so,

give address: ______

  1. To what extent will the care, custody and control of the child (for instance making decisions

regarding medical care, school and daily decisions) be exercised by:

a)person listed in No. 6 (person with whom child currently lives or will live):

______either parent: ______

  1. Does either parent hold a driver’s license? If so, from where?

Mother: Driver’s license # & State: ______

Father: Driver’s license # & State: ______

  1. For what address/property is each parent billed as a resident taxpayer:

______

  1. To what extent is the child’s support provided by:

a)person listed in No. 6:______either parent: ______

29. Is the child covered by health insurance? __ Yes __ No If yes, what adult’s name is the policy

issued or coverage provided: ______

30. What court orders, if any, have been issued with respect to the child/s guardianship and/or custody?

Attach copies of orders.

Date: ______Court: ______

Arrangements: ______

31. If the child is residing in a district other than that of either parent, explain the reason and

purpose for such an arrangement, including whether both parents have consented to such

arrangements. (Attach copies of any supporting documentation.) ______

______

32. Does either parent retain the right to recall the child from the person named in No. 6? If so,

under what circumstances?

______

33. Who is to receive school mailings?___ Mother___ Father___ Both___ Other

Name if other than parent: ______Home Phone: ______

Relationship: ______Work Phone: ______

Address: ______

34. Does this child temporarily live in Eastchester for the primary purpose of allowing the child to

attend the Eastchester schools? ___ Yes ___ No

35. Does this child live with a guardian for the primary purpose of enabling this child to attend the

Eastchester schools? ___ Yes ___ No

36. Who claims the child as a dependent on their Federal Income Tax Return? (You may be

required to supply copies) ______

EMERGENCY CONTACTS

37. Please supply two local emergency contacts, other than mom or dad, to be contacted incase of an

emergency involving this child:

  1. Name: ______Relationship:______

Address:______

Home #:______Cell #:______

  1. Name: ______Relationship:______

Address:______

Home #:______Cell #:______

Please sign below that you have understood the above questions and that the above answers are complete and accurate. The EastchesterSchool Districtmay seek tuition reimbursement for time enrolled, should the information provided be inaccurate. We reserve the right to remove your child from the district.

______

Signature Date

ACKNOWLEDGMENT

State of New York)

) ss.:

County of ______)

______being duly sworn, under penalty of perjury, deposes and says

(your name)

that deponent is the ______of ______; the deponent

(relationship to child) (child’s name)

has read the forgoing Application and knows the contents thereof; that the same are true to

deponent’s own knowledge and that deponent has given the answers set forth above knowing

that the EastchesterUnionFreeSchool District will rely upon them in determining whether the

child is to be admitted to its school system without being required to pay tuition. Deponent

agrees that he/she will be responsible for tuition in the event any answer in the application is

determined to be false.

______

Signature of Parent/Guardian

______

Print Name

Sworn to before me this

______day of ______, 20

______

Notary Public

1

Revised 10/22/14