Lakeland Regional High School District

LAKELAND REGIONAL HIGH SCHOOL DISTRICT

REGISTRATION INFORMATION FOR STATE RECORDS

NINTH GRADE REGISTRATION

DATE TODAY______ENTRY DATE______STUDENT ID ______LRHS ONLY

STUDENT INFORMATION:

DO NOT USE NICKNAMES: LIST CHILD’S FULL LEGAL NAME AS APPEARS ON BIRTH CERTIFICATE

NAME______

(Last Name) (First Name) (Full Middle Name)

DATE OF BIRTH______CITY AND STATE OF BIRTH ______COUNTRY OF BIRTH______

MALE____ FEMALE____ CURRENT AGE______

PLEASE READ AND SIGN THE STATEMENT BELOW BEFORE CONTINUING.

I CERTIFY THAT I AM THE LEGAL GUARDIAN AND CUSTODIAL PARENT OF THE STUDENT LISTED ABOVE AND HAVE THE AUTHORITY TO REGISTER THIS STUDENT AT LAKELAND REGIONAL HIGH SCHOOL.

X______

(Parent/Guardian Signature)

NAMES OF PARENTS/GUARDIANS/STEP PARENTS WITH WHOM CHILD RESIDES

PLEASE LIST CORRECT TITLE ON RELATIONSHIP LINE

______

(Parent/Guardian Last Name) (First Name) (Relationship)

______

(Parent/Guardian Last Name) (First Name) (Relationship)

HOME ADDRESS______(Number) (Street) (Town - Zip Code)

HOME TELEPHONE NUMBER ______

DETERMINATION OF HOMELESS STATUS – See description on back page. Does this apply to you? ___yes ____no

PLEASE LIST CELL PHONE AND E-MAIL INFORMATION FOR PARENTS/GUARDIAN WITH WHOM THE CHILD RESIDES.

FATHER CELL PHONE ______FATHER E-MAIL:______

MOTHER CELL PHONE ______MOTHER E-MAIL:______

ETHNIC ORIGIN: (Check one) White____ Black or African American____ American Indian/Alaskan Native____

Hispanic or Latino_____ Asian_____ Native Hawaiian or Other Pacific Islander_____

FIRST LANGUAGE SPOKEN IN HOME______

PLEASE COMPLETE OTHER SIDE OF REGISTRATION FORM

EMPLOYMENT INFORMANTION FOR PARENT/GUARDIAN: PLEASE CIRCLE CORRECT TITLE BELOW:

______

Father/Guardian/Step-Father Name OccupationEmployer Name(Area Code) Business Phone Number

______

Mother/Guardian/Step-Mother Occupation Employer Name(Area Code) Business Phone Number

EMERGENCY INFORMATION - PERSONS TO CALL:

The Lakeland Regional High School Crisis Management Plan has been developed in case a disaster occurs. Should there be such an emergency, or one of a personal nature (illness/accident), children may be released only to properly authorized parents/guardians or to the designees listed below.

NAME______RELATIONSHIP______

EMERGENCY CONTACT HOME TELEPHONE ______CELL NUMBER______

NAME______RELATIONSHIP______

EMERGENCY CONTACT HOME TELEPHONE ______CELL NUMBER______

DOCTOR’S NAME ______DOCTOR’S # ______

Does your child have Health Insurance?

YES____ If Yes, Name of Insurance Company:______

NO_____ IfNo, NJ Family Care provides free or low cost health insurance for uninsured children. For more information see Current Medical Information Form in registration packet.

List the Name, City and State of the Last Schoolyour child attended:

______

(School Name) (Number and Street Address)

______

(City) (State) (Zip Code)

I hereby certify that all the information provided on this form is true to the best of my knowledge.

X______X______

(Parent/Guardian Signature) (Student Signature)

Determination of Homeless Status:

A district board of education shall determine that a child is homeless when he or she resides in any of the following:

A publicly or privately operated shelter designed to provide temporary living accommodations, including:

Hotels or motels, congregate shelters, including domestic violence and runaway shelters, transitional housing and homes for adolescent mothers.

A public or private place not designated for, or ordinarily used as a regular sleeping accommodation, including:

Cars or other vehicles including mobile homes, tents or other temporary shelters, temporary shelters provided to migrant workers and their children on farm sites.

The residence of relatives or friends with whom the homeless child is temporarily residing out of necessity because the family lacks a regular or permanent residence of its own or any temporary location wherein children and youth are awaiting foster care placement.