Town of Lincoln Public Schools

O

Town of Lincoln Public Schools

District Registration Checklist

DOCUMENTS/INFORMATION NEEDED FOR REGISTERING A NEW STUDENT IN THE LINCOLN PUBLIC SCHOOLS. ALL LINES ON EVERY SHEET MUST BE FILLED IN.

_____ PARENT PHOTO IDENTIFICATION (I.E., LICENSE/PASSPORT) – ID WILL BE VERIFIED BY STAFF

_____ REGISTRATION FORM COMPLETED

_____ PROOF OF RESIDENCY

_____ STATE OF RHODE ISLAND PHYSICAL FORM COMPLETED AND SIGNED BY A PHYSICIAN

_____ CURRENT IMMUNIZATIONS

_____ HEALTH QUESTIONNAIRE

_____ HOME LANGUAGE SURVEY (Please make sure the Home Language Survey has ALL DATES filled in)

_____ RECORDS RELEASE

_____ CHILD’S ORIGINAL BIRTH CERTIFICATE/PASSPORT

______LEGAL GUARDIANSHIP/CAREGIVER AFFIDAVIT DOCUMENTS (IF APPLICABLE)

______LEGAL/PHYSICAL CUSTODY ORDERS/SEPARATION AGREEMENT (IF APPLICABLE)

_____ SPECIAL EDUCATION: INDIVIDUAL EDUCATION PLAN/TESTING 504 PLAN (IF APPLICABLE)

_____ INTERNATIONAL STUDENTS (COPY OF CHILD’S & PARENT’S PASSPORT AND ANY VISA J,L, R, G NOT B1 OR B2)

_____ STUDENT RECORDS/TRANSCRIPTS/REPORT CARDS

PROOF OF RESIDENCY

RENTER

______LEASE (MUST BE NOTARIZED OR ACCOMPANIED BY A NOTARIZED LETTER FROM THE LANDLORD)

______ONE CURRENT UTILITY BILL (GAS, OIL, ELECTRIC, TELEPHONE) OR EXCISE TAX BILL,

CAR INSURANCE STATEMENT, RHODEISLAND CAR REGISTRATION

HOMEOWNER

______MORTGAGE STATEMENT (ESTABLISHED HOMEOWNERS)

______EXECUTED PURCHASE AND SALES AGREEMENT WITH CLOSING DATE/MORTGAGE STATEMENT (NEW HOMEOWNERS)

______ONE CURRENT UTILITY BILL (GAS, OIL, ELECTRIC, TELEPHONE, CABLE) OR PROPERTY TAX BILL, FIRE TAX BILL, WATER BILL, EXCISE TAX BILL, CAR INSURANCE STATEMENT, RHODE ISLAND CAR REGISTRATION

______

Office Use Only

Student Start Date ______

Office Approval to Attend ______

Approval by Nurse ______

Bus Company Contacted ______Bus # ______

Revised 1/17/18

Town of Lincoln PublicSchoolsDistrictRegistration

Date ofEntry:

Grade:

Child’sName: Sex: M F Last First Middle

Date ofBirth: ______Place ofBirth:______

Child’sAddress:______

HomePhone: ______

Which of the following best describes your child? (Please circle one)

Alaskan Native American AsianPacific Islander

Hispanic Black (non-Hispanic) White (non-Hispanic)

Enrollmentisbasedonspaceavailability;therefore,astudent’sschoolassignmentmaybesubject tochange.

Father’sName:______Address:

HomePhone:____

Emailaddress:____

Employer:

CellPhone:___

Mother’sName:______Address:

HomePhone:___

Emailaddress:___

Employer:

CellPhone:__

Child ResidesWith:_

LegalGuardian:_

**Question of Custody will be clarified with the SchoolPrincipal

Other Children in theFamily:

Age

_Age _

Age

_Age _

2 original PROOF OF RESIDENCY DOCUMENTS REQUIRED:

Homeowner: Mortgage statement or Purchase & Sale agreement with closing date

Renter: Lease agreement(must be notarized OR accompanied by a notarized letter from the landlord)

ANDone of the following:

Utility Bill (gas,electric, telephone, cable) Property/Fire TaxBill

Water Bill Excise Tax Bill

Car Insurance Statement RI Car Registration

Signature of Person providing thisinformation:Information: _Relationship:

Date:_

Mandatory Information for Rhode Island Department ofEducation

(Middle and High SchoolOnly)

GuidanceCounselor ______

Year ofGraduation______

Town of Lincoln PublicSchools District Records ReleaseForm

Date://

I hereby authorize the School Districtof:

Name of Previous School: ______

Address: ______

Phone: ______Fax: ______

To release the complete school/confidential records (including health and academic records)and

IEP Records if applicable in your possession concerning mychild. Name:

Date ofBirth://

Release Recordsto:

CircleOne

SaylesvilleElementary50 WoodlandStreet

Lincoln, RI02865

P (401)723-5240

F (401)722-1090

Lincoln MiddleSchool152 Jenckes HillRoad Lincoln, RI02865

P (401)721-3400

F (401)721-3428

NorthernElementary315 New RiverRd.Manville, RI02838

P (401)769-0261

F (401)765-0530

Lincoln HighSchool 135 Old RiverRoad Lincoln, RI02865

P (401)334-7500

F (401)334-8753

CentralElementary1081 GreatRoad

Lincoln, RI02865

P (401)334-2800

F (401)334-4294

LonsdaleElementary270 RiverRoad

Lincoln, RI02865

P (401)725-4200

F (401)722-0920

Parent/GuardianSignature:

Relationship to child:

Student’s Name______DOB______Grade_____

STUDENT HEALTH SECTION

Physician’s Name ______Phone Number______

IF YOU ANSWER YES TO ANY QUESTION, PLEASE EXPLAIN

1. Has your child ever had any operations or serious illnesses? Yes No

If yes, please explain: ______

2. Has your child had any serious accidents? Yes No

If yes, please explain: ______

3. Does your child wear eyeglasses, contacts, braces, hearing aids, or any Yes No

other corrective devise?

If yes, please explain: ______

4. Has your child had the following (Give month, year and/or age if known):

Chicken Pox ______Yes No / Heart Condition ______Yes No
Pneumonia ______Yes No / Diabetes ______Yes No
Nosebleeds ______Yes No / Seizures ______Yes No
Frequent sore throats ______Yes No / High Fevers ______Yes No
Ear Infections ______Yes No / Migraines ______Yes No
Eye Condition ______Yes No / Other (Please specify) ______Yes No

5. Has your child been screened by a Speech/Language Therapist? Yes No

If yes, where? ______

6. Has your child had a neurological evaluation? Yes No

If yes, when? ______

7. Has your child had a psychological evaluation? Yes No

If yes, when? ______

8. Is your child restricted from physical activities? Yes No

If yes, please explain: ______

9. Is your child allergic to: medicines/drugs? Yes No

If yes, please specify: ______

Is your child allergic to: plants/foods? Yes No

If yes, please specify: ______

Is your child allergic to: insect stings? Yes No

If yes, please specify: ______

10. If you answered yes to question #9, does your child take medication for this allergy? Yes No

If yes, please specify (i.e. Benadryl, Epi-Pen, etc.): ______

11. Does your child have asthma? Yes No

If yes, what was the date diagnosed? ______

If yes, what medication(s) does he/she take? ______

12. Does your child take any daily medications? Yes No

If yes, please specify: ______

13. Will medication be given at school? Yes No

If yes, please specify: ______

14. What medications are given frequently, but not daily? ______

15. Would you like a conference with the school nurse? Yes No

Parent Name (Please Print) ______

PARENT SIGNATURE: ______DATE: ______

School Name &Address:Health Care Provider Name andAddress:

STATE OF RHODEISLAND SCHOOL PHYSICALFORM

Phone:

This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardizedformat withonecopyavailablefromtheRhodeIslandDepartmentofHealthorinanysuchformatthatcapturesthesamefieldsofinformation(R16-21SCHOSection8.4)

Student Name:Last / First / Middle / Date ofBirth / Sex
Address:Street / Apt# / City / State / ZipCode / HomePhone

PLEASECOMPLETEALLINFORMATIONBELOW(Mayattachimmunizationtranscript).

IMMUNIZATIONSPlease enter dates in MM/DD/YYYYformat
HepatitisB /
Diphtheria-Tetanus-PertussisDTP/DTaP / CheckifDT / CheckifDT / CheckifDT / CheckifDTCheckifDT
PneumococcalConjugatePCV
Polio
Haemophilus Influenzae TypeBHib
Measles-Mumps-RubellaMMR
Varicella / Student has history of varicelladisease
Tetanus-Diphtheria-PertussisTdaP/Td / CheckifTd / CheckifTd / CheckifTd
Rotavirus
HepatitisA
Meningococcal
HPV
Immunization Exemption: DMedicalDReligious
HepBDTaPPCVPolioHibMMRVaricellaTd/TdapRotavirusHepAMeningHPV
PHYSICALEXAMINATION
Date ofPE//HeightWeightBP
Pleasenoteanyhealthproblem,chronichealthconditionordisabilitythatmayaffectbehaviororhealthatschool:
ASTHMA:NoYesDIABETES:NoYesOTHER:
Significant SystemsFindings: ALLERGIES: No Yes(Pleaseexplain) EPINEPHRINEAUTO-INJECTORREQUIRED:NoYesTreatmentPlan: MEDICATION(REQUIREDATSCHOOL):No Yes(Pleaselist) Othermedication(s)thatmayaffectbehaviororhealthatschool: RESTRICTIONS: Can participate in physicaleducation: FullyD WithlimitationD
Can participate insports:FullyDWithlimitationD
LEAD SCREENING (Required for children < 6 years of ageonly)
Student is in compliance with lead screeningrequirements:
YesDNoD / SCOLIOSISSCREENING
YesDNoD / VISION SCREENING (Children enteringKindergarten)
DPassedscreening
D Screened and referred for comprehensiveexam
D Referred for comprehensive exam, but notscreened
TUBERCULOSIS (If required by schooldistrict)
Date of TBtest: / ScreeningDate: / ComprehensiveExamDate:

HEALTH CARE PROVIDERSIGNATURE:

DATE:

PRINTNAME:

Revised8-09

State of Rhode Island and ProvidencePlantations

DEPARTMENT OFEDUCATION

ShepardBuilding

255 WestminsterStreet

Providence, Rhode Island02903-3400

DeborahGist Commissioner

RHODE ISLAND HOME LANGUAGESURVEY

The information requested on this form is necessary for the most appropriate placement for your childas requiredbyRhodeIslandLaw(R.I.G.L.§16-54-2)andtheEqualEducationalOpportunityAct(20U.S.C.

§1703(f)) and will not be used for any other purposes. Thank you for yourcooperation. To be completed by parent orguardian:

StudentName:Country ofBirth

RegistrationDateof

Date:

Birth:_DateenteredUnitedStates:_

1.What language do you use most often when speaking to yourchild?

2.What language did your child first learn tospeak?

3.What language does your child use most often when speaking toyou?

4.Whatlanguagedoesyourchildusemostoftenwhenspeakingtootheradultsinthehomeortotheir primarycaretaker?

5.What language does your child use most often when speaking to siblings or other children in thehome?

6.What language does your child use most often when speaking to friends or neighbors outside thehome?

Signature of Parent orGuardianDate

Print Parent/GuardianName

Telephone(401)222-4600Fax(401)222-6178TTY800-745-5555Voice800-745-6575

The Board of Regents does not discriminate on the basis of age, color,sex, sexualorientation,race,religion,nationalorigin,ordisability

BUS TRANSPORTATION

STUDENT DATA FORM

The information requested below will be used to update and or assign students in the Versa-Trans computerized routing system. This system enables us to provide you with timely and accurate information. Please fill out this form if bus transportation is requested.

(School secretary: please fax this form immediately upon completion to First Student at 401-334-0576)

DATE: ______

PLEASE CIRCLE ONE:

NEW STUDENT CHANGE DELETION

NAME: ______

ADDRESS: ______

PARENT/GUARDIAN: ______

TELEPHONE # ______ALTERNATE # ______

SCHOOL: ______GRADE: ______

------

For First Student Bus Co. use only

BUS IN ______STOP ______TIME ______

BUS OUT ______STOP ______TIME ______