Home Zone / ID #
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

DATE

From

To
From
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/RECORDS
1.
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/Guardians
What 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)______

  1. 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)

  1. 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

  1. FOOD SERVICE APPLICATION? (Aplicación de Almuerzo)

YES NO

  1. 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.)

  1. 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)

  1. 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)

  1. 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

  1. FOOD SERVICE APPLICATION? (SOLICITAÇÃO PARA ALIMENTAÇÃO? )

YES/SIM NO.NÃO

  1. 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)

  1. 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)______

  1. 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)

  1. 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)

  1. FOOD SERVICE APPLICATION? (Aplicación de Almuerzo)

YES NO

  1. 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.)

  1. 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)

  1. 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)

  1. NURSE- ENFERMEIRA

(a) IMMUNIZATION RECORDS- COMPROVANTE DE VACINAS

YES/SIM NO/NÃO

(b) HEALTH REGISTRATION FORM/HEALTH INSURANCE INFORMATION

______YES/SIM NO/NÃO

  1. FOOD SERVICE APPLICATION? (SOLICITAÇÃO PARA ALIMENTAÇÃO? )

YES/SIM NO.NÃO

  1. 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)

  1. 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