Southington Public Schools

Southington Public Schools Student Registration Form

School Student will be attending: / Enrollment Date:
Entry Grade Level: / Graduation Year:
Student ID#: / CT SASID#:

Note: Student # will be assigned by computer unless student is returning to SPS. Obtain student #s from theSPS last attended.

Previous Information

Previous Address (if new to the district): / City/State:
School Last Attended: / City/State:
Grade Level from Previous School:

Has student ever been enrolled in the SouthingtonSchool District before? YES NO

If yes, which school: / Date Left:
Has the student attended Preschool? YES NO / If yes, name of facility:
Student’s Legal Last Name: / First: / Middle:*

*Middle Name Required. Check here if student does not have a middle name Has middle initial only

Birth Date: / Birth Place (City/State): / Gender / Male Female
Home Phone: / - - / Unlisted? YES NO
Home Address:
City: / State: / Zip:
Mailing Address
City: / State: / Zip:

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Language that the student learned first

Primary language spoken by students’ parents, guardians, or other

people with whom the student lives

Primary Language spoken by the student at home

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Ethnicity – Please respond to questions 1 and 2: (Official Federal Codes)

1. / Is the student Hispanic/Latino? YES NO
2. / Is the student from one or more races using the following (choose ALL that apply):
American Indian/Alaskan / Asian / Black or African American / Native Hawaiian or Other Pacific Islander / White

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Mother’s Maiden Name:

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Check Citizenship Status: / US Citizen / Dual National / Non-Resident / Alien Resident / Alien Other
If not an American Citizen, when did student enter the US? / Grade at first US School?

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Parent Guardian Information

Student lives with / Relationship to student

Mailing label header

Please Check One of the Following:

Two Parents in home Sole Custody Joint Custody Separated

Custody Transfer Foster Placement Emancipated Single Parent

Restrictions of Contact and Information (when applicable) Paperwork must be provided.

Order of protection Custody papers specify restriction Other documentation provided

Papers Provided Papers Provided Specify______

Name of Person Restricted: / Expiration Date:

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Mother’s Last Name: / First Name:
Address (if different from student):
City: / State: / Zip:
Hm Ph * / - - / Alt Ph * / - - / Wk Ph * / - -
*Indicate with a check mark the numbers we should use for the district School Messenger. The number checked will be used when the school/district has a message to deliver to all parents/guardians ~ we can call up to 3 phone numbers.
Email: / Employer:

Check all that apply: Receives Mailings Has Custody Living With

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Father’s Last Name: / First Name:
Address (if different from student):
City: / State: / Zip:
Hm Ph * / - - / Alt Ph * / - - / Wk Ph * / - -
*Indicate with a check mark the numbers we should use for the district School Messenger. The number checked will be used when the school/district has a message to deliver to all parents/guardians ~ we can call up to 3 phone numbers.
Email / Employer

Check all that apply: Receives Mailings Has Custody Living With

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Guardian Name / Relationship to student
Address (if different from student):
City: / State: / Zip:
Hm Ph * / - - / Alt Ph * / - - / Wk Ph * / --
*Indicate with a check mark the numbers we should use for the district School Messenger. The number checked will be used when the school/district has a message to deliver to all parents/guardians ~ we can call up to 3 phone numbers.
Email / Employer

Check all that apply: Receives Mailings Has Custody Living With

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Other Contact Name / Relationship to student
Address (if different from student):
City: / State: / Zip:
Hm Ph * / - - / Alt Ph * / - - / Wk Ph * / - -
*Indicate with a check mark the numbers we should use for the district School Messenger. The number checked will be used when the school/district has a message to deliver to all parents/guardians ~ we can call up to 3 phone numbers.
Email / Employer

Check all that apply: Receives Mailings Has Custody Living With************************************************************************************************************

PERMISSIONS AND CONFIDENTIALITY OF DIRECTORY INFORMATION

I give permission for my child to be photographed and/or videotaped at school for educational purposes, the school website or local media agencies. YES NO *If no, does that include the child’s photograph in the yearbook? YES NO

I do NOT want my child’s name, address, telephone number or date of birth released to any military recruiter without my prior approval. I understand that this will be in effect for the duration of my child’s enrollment at Southington High School.

I agree to the release of my child’s name, address, telephone number or date of birth to any military recruiter. I understand that this will be in effect for the duration of my child’s enrollment at Southington High School.

STUDENT INSURANCE COVERAGE

CT Public Act 07-04 requires families in public school districts to annually report whether the pupil hashealth insurance. This act also requires that we provide parents and guardians with informationregarding state-sponsored health insurance programs. Please respond accordingly:

My child currently has insurance coverage. YES NO

Will you insure your child with the school insurance program? YES NO

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Has your child participated in any of the following programs in any school? If yes, please indicate most recent year in program and what school.

SPECIAL EDUCATION/IEP / YES NO / If yes, what year / School
504 PLAN / YES NO / If yes, what year / School
ESL/ELL / YES NO / If yes, what year / School
GIFTED/TALENTED / YES NO / If yes, what year / School
SPEECH/LANGUAGE / YES NO / If yes, what year / School
TITLE I (CHAPTER I) / YES NO / If yes, what year / School
OTHER (Specify) / YES NO / If yes, what year / School

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EMERGENCY CONTACT(S)

IN CASE OF EMERGENCY, PARENTS/GUARDIANS WILL ALWAYS BE CONTACTED FIRST. PLEASE LIST ADDITIONAL PEOPLE THAT ARE AUTHORIZED TO PICK UP YOUR CHILD IN CASE YOU CANNOT BE REACHED (You may list up to 2 phone numbers for each contact)

Contact Name / Relation / Phone(must include area codes) / Extension
1 / ( ) -
( ) -
2 / ( ) -
( ) -
3 / ( ) -
( ) -
DR / DOCTOR / ( ) -

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Sibling(s)

Name / Date of Birth / School Attending
Name / Date of Birth / School Attending
Name / Date of Birth / School Attending

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PLEASE READ AND SIGN BELOW

The information on this form is accurate. I will notify the Southington Public Schools with information changes and updates

Parent/Guardian SignatureDate
Southington Public Schools

Southington, Connecticut

EMERGENCY MEDICAL AUTHORIZATION

Student’s Name / Sex / School / Grade
Home Address / Date of Birth
Mother’s Information (Full Name)
Home Ph / -- / Work Ph / -- / Cell/Emergency Ph / --
Father’s Information (Full Name)
Home Ph / -- / Work Ph / -- / Cell/Emergency Ph / --

In case of illness or accident during school hours when no one can be reached at home, please indicate below a person who may be contacted and/or transport your child.

1. / Emergency Contact Person / --

Relative/Neighbor Telephone

2. / Emergency Contact Person / --

Relative/Neighbor Telephone

HEALTH INFORMATION

Known Medical Problems
Medications
Known Allergies
Medications
Physician / Telephone / --
Hospital Choice / Insurance Company & Policy #

In an emergency, your child will be transported to the nearest medical facility to obtain appropriate treatment as deemed necessary by the local ambulance service.

I give permission for release of information on this form for confidential use in meeting my child’s health and educational needs in school.

I, the undersigned, do hereby authorize employees of the Southington Board of Education to contact directly the persons named on this form and do authorize the named physician to render such treatment as may be deemed necessary in an emergency for the health of said child.

In the event that the physician, other persons named on this card, or parents cannot be contacted, the school employees are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the aforesaid child.

The school district will not be held financially responsible for emergency care/or transportation for said child.

Signature of Parent/ Legal Guardian Date

Southington Board of Education

Registration Office

200 North Main Street

Southington, Connecticut06489

Phone (860) 628-3204Fax (860) 628-3205

Dear Parent/Guardian,

All new students are required to register at the Southington Board of Education Registration Office before they are admitted into the appropriate school. Parents/Guardians must verify residence in the Town of Southington, in person, at the Registration Office. The exception is parents/guardians of incoming kindergarteners. Kindergarten parents will be registering and submitting proof of residency at the districted school their child will be attending.

Currently enrolled students, who moved within town and need to change their address, must change their address at the Registration Office ~ even if the school district is not affected.

In order to complete the registration and residency verification you will need the following:

A full size birth certificate (not a wallet size) for all students born in the United States. Students born outside of the United States need to present a passport/visa or green card. Please note we do not accept foreign birth certificates.

Court issued guardianship documentation issued by the State of Connecticut if the parent of the child is not the legal guardian.

a.Homeowners must present one of the following: a current mortgage statement/bill, a copy of the Southington home property tax statement, or the title page of the current homeowner’s insurance policy.

b.Renters must present a current rental, lease agreement, or notarized letter from landlord or owner acknowledging the parent/guardian’s and student’s residence.

In addition, you must bring at least one current utility bill (electricity, gas, or phone).

If the student and the parent/guardian are living in a dwelling that is rented or owned and occupied by another person, a Certificate of Residence and affidavits will be filled out by the person with whom the family and student reside. The owner of the property will also be responsible for providing the district with the above documentation. Certificate of Residency forms will be available at the time of registration. Verification visit by Residency Officer may be required prior to the student beginning school.

*Verification of residency must be completed before the student will be admitted to any Southington Public School.