NEWBURYPORT PUBLIC SCHOOLS ENROLLMENT FORM
70 Low Street Newburyport, MA 01950 978-465-4456
Has your child ever been enrolled in any Newburyport Public School before? YesNo
Siblings within district?YesNoIf yes, please list information below:
NameSchoolGrade
______
______
Enrolling School:O HighO Rupert A. Nock Middle O Molin Upper Elementary
O BresnahanO Brown
O OPO OP-NFRO Related Services
STUDENT INFORMATION
______
Last NameFirst NameMiddle Name
Date of Birth:______City/Town of Birth:______Gender: MF
First Native LanguageCountry of Origin
(if other than English): (if other than US):
Home Phone:Alternate Phone:
Physical Address:Mailing Address: Is identical
Street: Street:
City: City:
State & Zip: State & Zip:
School Year:Grade Level:Date:______
Resident Member: ______ORChoice: ______Bus: ______Walker: ______
Is your child transferring from another school?YesNo
If yes, please list school name and location:
Has Student taken their Gr 10 MCAS?YesNoN/APassed all?
Is Student a member of a military family? Yes or No
Please complete:
Walker or Bus(include Bus #): Resident or School Choice:
Ethnicity (select only one)Hispanic or LatinoNot Hispanic or Latino
Race (select all that apply)AsianBlack or African American
CaucasianNative AmericanPacific Islander
Please indicate the Student’s current custodial status:
1.Live with both parents (same residence) _____
2.(separate residence-shared custody agreement) _____
3.If yes for #2, who has Legal* custody? ______
*Legal Physical Custody must be documented in order for N.P.S. to provide you with your child’s grade reports, etc. If you are not the custodial parent, you must provide legaldocumentation that you may be provided with information about your child. A letter from the custodial parent granting permission is also acceptable.
4. Lives with Mother _____ 5.Lives with Father _____
6. Lives with Guardian _____ Guardian’s Name: ______
Restraining Order? ______Against: ______
School use only:SPED Status: 504: LASID: ______
Counselor: ______PIN: ______Other Info: ______
Student’s Name: ______
PARENT/GUARDIAN CONTACT INFORMATION
FIRST CONTACT
FIRST NAMELAST NAMEHOME PHONE
PHYSICAL ADDRESS (STREET, CITY, STATE, ZIP)CELL PHONE
MAILING ADDRESS (IF DIFFERENT)EMAIL
RELATIONSHIP TO STUDENTPLEASE CHECK ALL THAT APPLY:
[ ]HAS CUSTODY
EMPLOYER[ ]LIVES WITH STUDENT
[ ]PICK-UP STUDENT
WORK PHONE (INCLUDE EXTENSION)
[ ]RECEIVE GRADE MAILING
ADDITIONAL PHONE OR EMAIL[ ]RECEIVE CONDUCT MAILING
[ ]RECEIVE OTHER MAILING
ADDITIONAL NOTES OR INFORMATION
SECOND CONTACT
FIRST NAMELAST NAMEHOME PHONE
PHYSICAL ADDRESS (STREET, CITY, STATE, ZIP)CELL PHONE
MAILING ADDRESS (IF DIFFERENT)EMAIL
RELATIONSHIP TO STUDENTPLEASE CHECK ALL THAT APPLY:
[ ]HAS CUSTODY
EMPLOYER[ ]LIVES WITH STUDENT
[ ]PICK-UP STUDENT
WORK PHONE (INCLUDE EXTENSION)
[ ]RECEIVE GRADE MAILING
ADDITIONAL PHONE OR EMAIL[ ]RECEIVE CONDUCT MAILING
[ ]RECEIVE OTHER MAILING
ADDITIONAL NOTES OR INFORMATION
Student’s Name: ______
THIRD CONTACT
FIRST NAMELAST NAMEHOME PHONE
PHYSICAL ADDRESS (STREET, CITY, STATE, ZIP)CELL PHONE
MAILING ADDRESS (IF DIFFERENT)EMAIL
RELATIONSHIP TO STUDENTPLEASE CHECK ALL THAT APPLY:
[ ]HAS CUSTODY
EMPLOYER[ ]LIVES WITH STUDENT
[ ]PICK-UP STUDENT
WORK PHONE (INCLUDE EXTENSION)
[ ]RECEIVE GRADE MAILING
ADDITIONAL PHONE OR EMAIL[ ]RECEIVE CONDUCT MAILING
[ ]RECEIVE OTHER MAILING
ADDITIONAL NOTES OR INFORMATION
FOURTH CONTACT
FIRST NAMELAST NAMEHOME PHONE
PHYSICAL ADDRESS (STREET, CITY, STATE, ZIP)CELL PHONE
MAILING ADDRESS (IF DIFFERENT)EMAIL
RELATIONSHIP TO STUDENTPLEASE CHECK ALL THAT APPLY:
[ ]HAS CUSTODY
EMPLOYER[ ]LIVES WITH STUDENT
[ ]PICK-UP STUDENT
WORK PHONE (INCLUDE EXTENSION)
[ ]RECEIVE GRADE MAILING
ADDITIONAL PHONE OR EMAIL[ ]RECEIVE CONDUCT MAILING
[ ]RECEIVE OTHER MAILING
ADDITIONAL NOTES OR INFORMATION