Vernon Public School Registration Formdate Completed:______

Vernon Public School Registration FormDate Completed:______

STUDENT INFORMATION:
Last Name: ______First Name: ______Middle Name: ______Suffix: ___ Check one: Male □ Female □
Address______Apt. #______Town______Zip Code______Phone Number (Area Code): Unlisted? □
Mailing Address (if different from above) ______
Date of Birth: ___Place of Birth (City): ______(State): _ (Country): ______
Student Email Address (if applicable): ______
Student lives with: □ Both parents / □ Mother / □ Father / □ Step-parent / □ Guardian / □ DCF Worker □ Other______
What is the student’s ethnicity/race: (Please check ALL that apply.)
Hispanic / Latino
(Please circle one) / AND / American Indian or Alaskan Native / Asian / Black or African American / Native Hawaiian or Other Pacific Islander / Caucasian
Yes or No
FAMILY INFORMATION
PARENT/GUARDIAN 1: ______
(LAST) (FIRST)
Legal Status:□ Custodial □ Non-custodial If Parent, are there any parental restrictions? □ Yes □ No ______(Court document required if yes)
Address: ______Phone 1*: ______home / work / cell
Email Address *:______Phone 2: ______home / work / cell
Employer:______Phone 3: ______home / work / cell
Active Military: Yes □ No □

PARENT/GUARDIAN 2: ______
(LAST) (FIRST)
Legal Status:□ Custodial □ Non-custodial If Parent, are there any parental restrictions? □ Yes □ No ______(Court document required if yes)
Address: ______Phone 1*: ______home / work / cell
Email Address *:______Phone 2: ______home / work / cell
Employer:______Phone 3: ______home / work / cell
Active Military: Yes □ No □
* Connect5 Emergency Notification Servicewill be used to communicate emergency and general messages to Families/Guardians via an automatic call or email initiated by the Superintendent/Principal. (Examples: Emergency – early dismissal and General – School event). These are the phone numbers and email addresses highlighted above. Please identify here if you have an additional number or email that you would like contacted:______
Siblings (please list names of student’s brothers and sister in order):
Sibling 1. ______School: ______Sibling 3. ______School: ______
Sibling 2. ______School: ______Sibling 4. ______School: ______
Please identify 2 people we can contact if you cannot be reached during the school day that can dismiss and receive student:
Emergency Contact 1: ______Relationship: ______Phone: ______
Address: ______Town: ______State: ______Zip: ______
Emergency Contact 2: ______Relationship: ______Phone: ______
Address: ______Town: ______State: ______Zip: ______
Does the student lack a fixed regular/adequate nighttime residence? Yes □ No □
Has this student ever attended school in Vernon before? Yes □ No □ Name of Vernon school: ______
What town did you previously live in?: ______Name of prior school: ______
School Counselor (if known):______
Has your child been in any gifted or accelerated classes? Yes □ No □ What type of classes? ______
Has your child received extra help/support in school? Yes □ No □ What type of services? ______
Has your child ever been retained? Yes □ No □ What grade? ______
Has your child ever been expelled? Yes □ No □ Dates ______
INSTRUCTIONAL PROGRAM INFORMATION (Please circle any that apply)
Does/did the student receive Special Education Services in accordance with an Individual Education Plan (IEP)?: Yes □ No □
If yes, can you provide a copy of the last IEP? Yes □ No □
Does this student have a 504 plan? Yes □ No □
If yes, do you have a copy of the last 504 that we may have? Yes □ No □
Are there any conditions (physical, medical, legal) that may affect school participation? Yes □ No □
If yes, please explain: ______
______
ADDITIONAL INFORMATION:
______
______
IF REGISTERING FOR KINDERGARTEN: Please check the box that best describes your child’s routine activity the year prior to entering Kindergarten.
□ Attended Head Start Program□ Attended Vernon Public School Preschool Program□ Attended a Private Nursery/Preschool□ Attended a Family Resource Center Program
□ Daycare provided by family, friend or daycare provider□Attended public school preschool in another district□ Did not attend any of the above□ Remained at home
Office Use Only SASID#:______LASID#: ______Grade: ______School:______
Enrollment Status: □ New □ Attending magnet school □ Homeschooling □ Re-enrolling □ Open Choice Scanned into Aspen □