Assigned School / Homeroom / Program
LONG BRANCH PUBLIC SCHOOLS REGISTRATION FORM (Gr. 1-12)
Long Branch, New Jersey
Today’s Date: / Home Phone #
Entering Grade: / Cell Phone #
Entry Date: / Mother’s Work Phone #
Father’s Work Phone #
NAME OF CHILD
LAST / FIRST / MI
ADDRESS / Apt #
Long Branch, NJ07740
CLOSEST CORNERS TO HOME
STREET AND / STREET
DATE OF BIRTH / GENDER: / MALE / FEMALE
MONTH / DAY / YEAR
RACE: (CIRCLE ONE) / I / Amer. Indian/Alaskan / A / Asian / B / Black Not Hispanic
H / Hispanic / W / White M / Multi Racial
P Pacific Islander
BIRTH PLACE
CITY / STATE / COUNTRY / ENTRY DATE
LASTSCHOOL ATTENDED
SCHOOL NAME / CITY / STATE
WHAT LANGUAGE IS SPOKEN AT HOME?
HAS CHILD PREVIOUSLY ATTENDED SCHOOL IN THE U.S.? / YES / NO
HAS CHILD PREVIOUSLY ATTENDED SCHOOL IN LONG BRANCH? / YES / NO
PARENT / LEGAL GUARDIAN / FOSTER PARENT
PARENTS :
NAME
MOTHER AND/OR FATHER FIRST & LAST NAMES / HOME PHONE
ADDRESS
CELL PHONE
LEGAL GUARDIAN OR FOSTER PARENT:
NAME / AFFIDAVIT OF SUPPORT
ADDRESS
HOME PHONE CELL PHONE
EMERGENCY NOTIFICATION (Parent/Guardian will be called first)
NAME / HOME PHONE
ADDRESS / WORK PHONE
OTHER CHILDREN IN FAMILY (Please list oldest first)
NAME / SEX / DATE OF BIRTH / SCHOOL / GRADE
RECORD OF TRANSFERS
CROSS
OUT ONE /CITY
/STATE
/SCHOOL ADDRESS
/ REASON /ENTRY
DATE /LAST
DATEFrom
ToFrom
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
RECORDS ACCESS
PRINT NAME/SIGNATURE / REASON / DATE / TIME/CIRCUMSTANCE/RECORDS1.
2.
3.
4.
5.
6.
7.
LONG BRANCH PUBLIC SCHOOLS
LONG BRANCH, NEW JERSEY
Our school district is participating in a system where the federal government’s Medicaid will pay state and local school districts for a portion of the costs of health-related special education services provided to Medicaid eligible children. Your child will continue to receive services at no cost to you under this new system. This initiative simply helps us maximize federal funds in support of local education. The information you voluntarily provide by completing this consent form will only be used for the purposes identified.
Please fill in the information below, sign the form, and return it to the address indicated:
CONSENT FOR RELEASE OF INFORMATION TO ACCESS MEDICAID
REIMBURSEMENT FOR HEALTH RELATED SUPPORT SERVICES(Name of parent or person in parental relationship)
CHILD’S NAME
(First)(Middle Initial)(Last)
CHILD’S MEDICAID NUMBER
CHILD’S DATE OF BIRTH //
As parent/guardian of the child named above, I give permission to disclose information from my child’s educational records to local,
state and federal agency representatives for the sole purpose of claiming Medicaid reimbursement for health related support services
in my child’s Individualized Education Program (IEP).
Signature:Date:
(Parent or person in parental relationship) (month/day/year)
Please return this form to:
Home Language Survey
New Jersey Department of Education regulations require that all schools determine the language(s) spoken in each student’s home in orderto identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.
Student Information______F F M
First NameMiddle NameLast NameGender
////______
Country of Birth Date of Birth (mm/dd/yyyy)Date first enrolled in ANYU.S. school(mm/dd/yyyy)
School Information/ / 20______
Start Date in NewSchool (mm/dd/yyyy)Name of Former School and Town Current Grade
Questions for Parents/GuardiansWhat is the native language(s) of each parent/guardian? (circle one)
______Mother
______Father
______Guardian / Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
______sometimes/often/always
______sometimes/often/always
What language did your child first understand and speak? / Which language do you use most to communicate with your child?
Which other languages does your child know? (circle all that apply)
______speak / read / write
______speak / read / write / Which languages does your child use to communicate? (circle one)
______sometimes/often/always
______sometimes/often/always
Will you require written information from school in your native language? Yes No / Will you require an interpreter/translator at Parent-Teacher meetings?
Yes No
Parent/Guardian Signature:
X / _____/ /20______
Today’s Date: (mm/dd/yyyy)
*Please note copies of any Home Language survey that indicates another language other than English in the above questions must be submitted to the Bilingual Office at 540 Broadway, Long Branch 07740*
LONG BRANCH PUBLIC SCHOOLS
LONG BRANCH, NEW JERSEY
ELEMENTARY SCHOOL REGISTRATION CHECKLIST
(Documentaciones necesarias para Matricularse en la Escuela Intermedia o Secundaria )
STUDENT NAME(NOMBRE/ ESTUDIANTE)DATE(FECHA)______
- REGISTRATION(MATRÍCULA)
(a) PROOF OF RESIDENCY (PRUEBA DE RESIDENCIA EN LONG BRANCH)
Copy of lease – if renting(Contrato de renta-si alquila)
Copy of closing – if purchasing home (Contrato de cierre-si adquirio casa)
Copy of utility bill(s) dated(Copia de factura –fechada)
Telephone Date
Electric Date
Fuel Date
Water Date
Notarized Date
Affidavit
(b) PROOF OF BIRTHDAY (Prueba de Nacimiento)
YES NO
Birth Certificate(Certificado de Nacimiento)
Passport (Pasaporte)
Baptismal Certificate (Certificado de Bautismo)
Other (otros) (specify)(explique)
- NURSE (Enfermera)
(a) IMMUNIZATION RECORDS(Record de Vacunas)
YES NO
(b) HEALTH REGISTRATION FORM (Formulario de Historial de Salud)
______YES NO
(c) HEALTH INSURANCE INFORMATION (Información de Seguro medico)
______YES ______NO
- FOOD SERVICE APPLICATION? (Aplicación de Almuerzo)
YES NO
- LANGUAGE SURVEY – If the child speaks another language besides English,
please have parent fill out the Language Survey.(Pida a los padres completar el cuestionario si hablan otro idioma además de Inglés.)
- SCHOOL RECORDS & TRANSFER SCHOOL CARD(Libreta de calificaciones y tarjeta de transferencia de Escuela)
ALL REGISTRATION REQUIREMENTS MUST BE MET
BEFORE CHILD CAN ATTEND SCHOOL
Mr. Francisco RodriguezMrs. Marissa FornicolaMr. Christopher Volpe
AnastasiaSchoolAudreyW.ClarkSchoolWest EndSchool
732-571-3396732-571-4677732-222-3215
Mrs. Ivette RiciglianoMr. Elford Rawls-DillMrs. Bonita Potter-Brown
MorrisAvenueSchoolGregorySchoolLennaW.ConrowSchool
732-571-3139732-222-7048732-222-4539
Mrs. Loretta JohnsonMrs. Donna Critelli
Joseph M. Ferraina Early ChildhoodLearningCenterTransportation Manager
732-571-4150732-571-2868, Ext. 40080
ELEMENTARY SCHOOL REGISTRATION CHECKLIST
Formulario de Matrícula para Escolas Secundárias e Intermediárias
STUDENT NAME (Nome do aluno(a):DATE (data)
- REGISTRATION- MATRĺCULA
(a) PROOF OF RESIDENCY- COMPROVANTE DE RESIDÊNCIA
Copy of lease – if renting – Copia de Contrato de Arrendamento
Copy of closing – if purchasing home Comprovação de Casa Própria
Copy of utility bill(s) dated (Copia de Conta de utilidade pública datada)
Telephone - Telefone Date
Electric - Eletricidade Date
Fuel -Gás Date
Water -Água Date
Notarized Date
Affidavit (Carta comprovando endereço notarizada)
(b) PROOF OF BIRTHDAY- COMPROVANTE DE NASCIMENTO
YES/SIM NO/NÃO
Birth Certificate – CERTIDÃO DE NASCIMENTO
Passport - PASSAPORTE
Baptismal Certificate –CERTIDÃO DE BATISMO
Other-OUTRO (especificar)
- NURSE- ENFERMEIRA
(a) IMMUNIZATIONS UP-TO- DATE
(Vacinas pôr em dia)
YES/SIM NO/NÃO
(b) HEALTH REGISTRATION FORM/HEALTH INSURANCE INFORMATION
______YES/SIM NO/NÃO
- FOOD SERVICE APPLICATION? (SOLICITAÇÃO PARA ALIMENTAÇÃO? )
YES/SIM NO.NÃO
- LANGUAGE SURVEY – If the child speaks another language besides English,
please have parent fill out the Language Survey.
(Se o aluno falar outro idioma além do Inglês, os pais devem preencher o questionário de idioma)
- SCHOOL RECORDS & TRANSFER SCHOOL CARD- -
FICHA INDIVIDUAL DO ALUNO & CARTA DE TRANSFERÊNCIA ESCOLAR
ALL REGISTRATION REQUIREMENTS MUST BE MET
BEFORE CHILD CAN ATTEND SCHOOL
ALL REGISTRATION REQUIREMENTS MUST BE MET
BEFORE CHILD CAN ATTEND SCHOOL
Mr. Francisco RodriguezMrs. Marissa FornicolaMr. Christopher Volpe
AnastasiaSchoolAudreyW.ClarkSchoolWest EndSchool
732-571-3396732-571-4677732-222-3215
Mrs. Ivette RiciglianoMr. Elford Rawls-DillMrs. Bonita Potter-Brown
MorrisAvenueSchoolGregorySchoolLennaW.ConrowSchool
732-571-3139732-222-7048732-222-4539
Mrs. Loretta JohnsonMrs. Donna Critelli
Joseph M. Ferraina Early ChildhoodLearningCenterTransportation Manager
732-571-4150732-571-2868, Ext. 40080
LONG BRANCH PUBLIC SCHOOLS
LONG BRANCH, NEW JERSEY
HIGH SCHOOL & MIDDLE SCHOOL REGISTRATION CHECKLIST
(Documentaciones necesarias para Matricularse en la Escuela Intermedia o Secundaria )
STUDENT NAME(NOMBRE/ ESTUDIANTE)DATE(FECHA)______
- REGISTRATION(MATRÍCULA)
(a) PROOF OF RESIDENCY (PRUEBA DE RESIDENCIA EN LONG BRANCH)
Copy of lease – if renting(Contrato de renta-si alquila)
Copy of closing – if purchasing home (Contrato de cierre-si adquirio casa)
Copy of utility bill(s) dated(Copia de factura –fechada)
Telephone (Telefono) Date
Electric(Electricidad) Date
Fuel (Gas) Date
Water (Agua) Date
Notarized Date
Affidavit (Carta de prueba de dirección notarizada)
(b) PROOF OF BIRTHDAY(Prueba de Nacimiento)
YES NO
Birth Certificate(Certificado de Nacimiento)
Passport (Pasaporte)
Baptismal Certificate (Certificado de Bautismo)
Other (otros) (specify)(explique)
- NURSE (Enfermera)
(a) IMMUNIZATION RECORDS(Record de Vacunas)
YES NO
(b) HEALTH REGISTRATION FORMATION (Formulario de Historial de Salud)
______YES NO
(c) HEALTH INSURANCE INFORMTION (Información de Seguro Medico)
- FOOD SERVICE APPLICATION? (Aplicación de Almuerzo)
YES NO
- LANGUAGE SURVEY – If the child speaks another language besides English,
please have parent fill out the Language Survey.(Pida a los padres completar el cuestionario si hablan otro idioma además de Inglés.)
- SCHOOL RECORDS & TRANSFER SCHOOL CARD(Libreta de calificaciones y tarjeta de transferencia de Escuela)
ALL REGISTRATION REQUIREMENTS MUST BE METBEFORE CHILD CAN ATTEND SCHOOL
Todos Los Requisitos De Registración Deben Ser Cumplidos Antes De Que El Niño/a Pueda Atender A La Escuela
Mr.V.J. MuscilloMrs. Kristin FerraraMs. April Morgan
Principal High SchoolHigh School
High SchoolVisual & Performing ArtsSchool of Science, Technology,
732-229-7300 x41004732-229-7300 x41020Engineering &Mathematics (STEM)
732-229-7300 x41030
Mr. Frank Riley Ms. Carmen VegaMr. Donald Covin
High SchoolAlternative ProgramMiddle School
Leadership H.S. & M.S.Leadership
732-229-7300 x41010732-728-9090732-229-5533 x42030
Mr. Matthew JohnsonMr. Michael Viturello
Middle SchoolMiddle School
Visual & Performing ArtsScience & Computer Technology
732-229-5533 x42010732-229-5533 x42020
LONG BRANCH PUBLIC SCHOOLS
LONG BRANCH, NEW JERSEY
HIGH SCHOOL & MIDDLE SCHOOL REGISTRATION CHECKLIST
Formulario de Matrícula para Escolas Secundárias e Intermediárias
STUDENT NAME (Nome do aluno(a):DATE (data)
- REGISTRATION- MATRĺCULA
(a) PROOF OF RESIDENCY- COMPROVANTE DE RESIDÊNCIA
Copy of lease – if renting – Copia de Contrato de Arrendamento
Copy of closing – if purchasing home Comprovação de Casa Própria
Copy of utility bill(s) dated (Copia de Conta de utilidade pública datada)
Telephone - Telefone Date
Electric - Eletricidade Date
Fuel - Gás Date
Water - Água Date
Notarized Date
Affidavit (Carta comprovando endereço notarizada)
(b) PROOF OF BIRTHDAY- COMPROVANTE DE NASCIMENTO
YES/SIM NO/NÃO
Birth Certificate - CERTIDÃO DE NASCIMENTO
Passport - PASSAPORTE
Baptismal Certificate - CERTIDÃO DE BATISMO
Other-OUTRO (especificar)
- NURSE- ENFERMEIRA
(a) IMMUNIZATION RECORDS- COMPROVANTE DE VACINAS
YES/SIM NO/NÃO
(b) HEALTH REGISTRATION FORM/HEALTH INSURANCE INFORMATION
______YES/SIM NO/NÃO
- FOOD SERVICE APPLICATION? (SOLICITAÇÃO PARA ALIMENTAÇÃO? )
YES/SIM NO.NÃO
- LANGUAGE SURVEY – If the child speaks another language besides English,
please have parent fill out the Language Survey.
(Se o aluno falar outro idioma além do Inglês, os pais devem preencher o questionário de idioma)
- SCHOOL RECORDS & TRANSFER SCHOOL CARD- -
FICHA INDIVIDUAL DO ALUNO & CARTA DE TRANSFERÊNCIA ESCOLAR
ALL REGISTRATION REQUIREMENTS MUST BE MET
BEFORE CHILD CAN ATTEND SCHOOL
Todos os requerimentos para matrícula devem estar completosAntes que o aluno possa freqüentar a escola
Mr. V.J. Muscillo Mrs. Kristin FerraraMs. April Morgan
Principal High SchoolHigh School
High SchoolVisual & Performing ArtsSchool of Science, Technology, Engineering &
732-229-7300 x41004732-229-7300 x41020Mathematics (STEM)
732-229-7300 x41030
Mr. Frank Riley Ms. Carmen VegaMr. Donald Covin
High SchoolAlternative ProgramMiddle School
Leadership H.S. & M.S.Leadership
732-229-7300 x41010732-728-9090732-229-5533 x42030
Mr. Matthew JohnsonMr.Michael Viturello
Middle SchoolMiddle School
Visual & Performing ArtsScience & Computer Technology
732-229-5533 x42010732-229-5533 x42020
LONG BRANCH PUBLIC SCHOOLS
Long Branch, New Jersey
NURSING SERVICES
CONFIDENTIAL HEALTH HISTORY
______
Child’s Name (Last, First)Date of Birth
Adopted or Foster Child (circle one): YesNo
Age of child at adoption or foster placement: ______Birth mother living? ______
Does child have relationship with birth mother/father?
DEVELOPMENTAL INFORMATION
*Pre-natal History
Length of pregnancy: ______Maternal age at birth: ______Weight gain: ______
Total pregnancies (including child):______Living children:______
Significant stressful events during pregnancy: ______
Maternal acute illness during pregnancy: ______
Maternal chronic illness during pregnancy: ______
Medications (Rx & OTC), street drugs, alcohol, smoking during pregnancy:
______
Any other significant events:
*Post-natal History
Delivery: _____Vaginal ____Forceps ____C-section
Anesthetic:______
Length of labor: ______(hrs.) Complications:______
Length of hospital stay: ______(mother)______(infant)
Birth weight: ______lbs. ______oz.
Feeding: _____Breast (# months ______)Bottle:______Difficulties?______
Any other significant events:______
*Developmental Milestones
Age child crawled: ______Sat alone: ______Stood alone: ______
Age child walked: ______Spoke words:______
Spoke short sentences:______
Fed self:______Eat nonfoods?______Dress self:______
Bladder control:______Bowel control:______
Has child attended preschool/day care?______
Does child suck his/her thumb?______Is child clumsy?______
Does child have temper tantrums or act aggressively?______How often?______
Does your child have difficulty speaking or listening?______
Do you have any concerns about your child and his/her adjustment to school?
______
LONG BRANCH PUBLIC SCHOOLS
Long Branch, New Jersey
HEALTH REGISTRATION FORM
Transferred from:______
Date:______
Has student ever attended school in Long Branch? ____ Yes_____ No Year ______
Student’s Name (Last, First)AddressPhone
Father’s NameMother’s NameGuardian’s
Date of BirthMale/FemalePhysician Dentist
Yes___we do have Health Insurance: Provider name______
No ___ we do not have Insurance but would like further information.
DISEASE AND ILLNESS HISTORY: (note year)
Medications______Heart Condition______
Diet Restrictions______Rheumatic Fever______
Serious Illness(es)______Seizures______
Chronic Illness(es)______Lead Poisoning______
Chicken Pox______Frequent Colds______
Asthma______Ear Infections______
German Measles______Visual Difficulty______
Allergy______Hearing Difficulty______
Measles______Accidents/ERVisits______
Diabetes______Concussion______
: Blood Sugars/medication______Neurological ______Hospitalization______GI illnesses ______
Anemia______Operations______
Whooping Cough______Tuberculosis Exposure______
Kidney Disease______Sickle Cell______
Other______
------
Were immunization records submitted?Yes _____No _____
Are immunization records up to date?Yes _____No _____
Was physical exam form given to family
and explained?Yes _____No _____
Are there religious considerations regarding
Medical treatment/immunizationsYes _____No _____
Revised March 09
OFFICE OF THE SUPERINTENDENT
LONG BRANCH PUBLIC SCHOOLS
540 BROADWAY, LONG BRANCH, NEW JERSEY 07740
Michael Salvatore
Superintendent of Schools
(732) 571-2868, Ext. 40010
Fax: (732) 229-0797
It has been brought to my attention that your son/daughter ______needs the following vaccinations:
______
______
If these shots are not administered your child will be suspended from attending school. You can call the MonmouthCareCenter at 732-923-7100 for an appointment or you can call the Head Nurse, Kathleen Celli at 732-229-7300 Ext 41651 for more information.
c: Principal
Nurse
Revised Jan. 12
LONG BRANCH PUBLIC SCHOOLS
Long Branch, New Jersey
ELEMENTARY MAGNET PROGRAMS
PARENT CHOICE FORM
Dear Parent/Guardian:
Please indicate your choice by placing 1, 2, or 3 in front of the magnet choice. We will attempt to give you your first or second choice, however, we must consider the balancing of classes with regard to race, sex, and class size. Please keep in mind: (1) the Core Curriculum is the same in all schools; (2) the magnet programs provide a theme of activities that compliment the core subjects; and (3) all classrooms have computers, a teacher work station, and all schools have a computer lab.
MAGNET PROGRAMS
Metropolis, A Unique Community MagnetGregorySchool: PreK-5
PreK 8:50 a.m. – 2:50 p.m.
K-5 8:50 a.m. – 3:30 p.m.
Science Computer Technology MagnetMorris Avenue School: PreK-2
PreK7:50 a.m. – 1:50 p.m.
K-27:50 a.m. – 2:30 p.m.
AudreyW.ClarkSchool:PreK & 3-5 PreK 9:00 a.m. – 3:00 p.m.
AudreyW.ClarkSchool: 3-5
3-57:50 a.m. – 2:30 p.m.
Marine Environmental Science MagnetA. A.Anastasia:PreK-5
Talented ProgramPreK 9:00 a.m. – 3:00 p.m.
K-5 8:35 a.m. – 3:15 p.m.
Future Leaders MagnetWest EndSchool: K-5
K – 5 8:50 a.m. – 3:30 p.m.
Long Branch Public Schools provide a free breakfast program to every student.
The program begins 20 minutes before the start of the school day (listed above).
□ Indicate if you request Assessment for our Bilingual program.
Parent/Guardian SignatureDate
Child’s Name Phone Number
Address
I have made my choices in order to have my children on the same school schedule. Yes No
(If the answer is “Yes”, fill out the following information on the other child(ren).)
Sibling’s Name(s)Grade(s)School
Revised: 5/22/07 MS Revised: 7/24/09
Revised 9/6/11
LONG BRANCH PUBLIC SCHOOLS
Long Branch, New Jersey
HIGH SCHOOL ACADEMY PROGRAMS
PARENT CHOICE FORM
Dear Parent/Guardian:
Please indicate your choice by placing 1, 2, or 3 in front of the magnet choice. We will attempt to give you your first or second choice, however, we must consider the balancing of classes with regard to race, sex, and class size. Please keep in mind: (1) the Core Curriculum is the same in all academies; (2) the magnet programs provide a theme of activities that compliment the core subjects; and (3) all classrooms have computers, a teacher work station, and all academies have a computer lab.
SCHOOL PROGRAMS
School of LeadershipGr. 9 - 12
7:55 a.m. – 2:50 p.m.
______School of Science, Technology, Gr. 9 - 12
Engineering, & Mathematics 7:55 a.m. – 2:50 p.m.
______Academy of Visual & Performing ArtsGr. 9 - 12
7:55 a.m. – 2:50 p.m.
Long Branch Public Schools provide a free breakfast program to every student.
The program begins 20 minutes before the start of the school day (listed above).
□ Indicate if you request Assessment for our Bilingual program.
Parent/Guardian SignatureDate
Child’s Name Phone Number
Address
Sibling’s Name(s)Grade(s)School
Revised 5/22/07 MS
Revised: 7/24/09
LONG BRANCH PUBLIC SCHOOLS
Long Branch, New Jersey
MIDDLE SCHOOL ACADEMY PROGRAMS
PARENT CHOICE FORM
Dear Parent/Guardian:
Please indicate your choice by placing 1, 2, or 3 in front of the magnet choice. We will attempt to give you your first or second choice; however, we must consider the balancing of classes with regard to race, sex, and class size. Please keep in mind: (1) the Core Curriculum is the same in all academies; (2) the magnet programs provide a theme of activities that compliment the core subjects; and (3) all classrooms have computers, a teacher work station, and all academies have a computer lab.
ACADEMY PROGRAMS
Academy of Science &Gr. 6-8
Computer Technology8:30 a.m. – 3:18 p.m.
Academy of Visual & Gr. 6 -8
Performing Arts8:30 a.m. – 3:18 p.m.
__Academy of Leadership Gr. 6 -8
8:30 a.m. – 3:18 p.m.
Long Branch Public Schools provide a free breakfast program to every student.
The program begins 20 minutes before the start of the school day (listed above).
□ Indicate if you request Assessment for our Bilingual program.
Parent/Guardian SignatureDate
Child’s Name Phone Number
Address
Sibling’s Name(s)Grade(s)School
Revised 5/22/07 MS
Revised: 7/24/09