Post on 28-Jul-2018
Union City Board Of Education ALL DOCUMENTS PRESENTED MUST BE ORIGINAL©
Students must be present with parent or legal guardian to register
Pre-school children must be 3, 4 and 5 years of age on or before September 1
"Proof of Residence" Picture ID from Parent or Legal Guardian -‐ select ONE from list below:
__ Current Driver's License __ Current NJ State ID Card __ Valid Passport
TWO (2) Proofs of Residency from Parent or Legal Guardian with their name & address on document:
__ Employment or un-‐ employment document or Health Benefits Card or Welfare documents.
__ Voter registration card
__ Utility: PSE&G, Water or Cable
__ Property Owner:
Property tax bills, deed, contract of sale, mortgage, and other evidence of property ownership.
__ Property Owner and Tenant: A Lease of agreement with rent receipt, including deposit slip demonstrating the property address and tenant name.
__ Military status including assignment documents.
Note:
If the child’s last name differs from the last name of parent (s), proof of parentage is required. Parent’s name change must be documented (i.e. marriage or divorce certificate)
"Student Certificates"
__ Birth Certificate , Passport or Baptismal Certificate.
__ Immunization Records showing all immunizations are current.
TB SKIN TEST (MANTOUX method of PPD TEST). Students cannot register until after the TB, skin test has been read and the doctor/clinic has provided you with written results. If the TB test is positive, student needs to provide proof of normal chest X-‐ray and/or proof of INH medication treatment including dosage, date started and date completed.
__ Medical “State of New Jersey Physician Form for Union City”
__ Report Card and prior school records. Transfer Card/Withdrawal Form from the previous school. Both the transcript and withdrawal form help our counselors place your student in the most appropriate classes for academic success.
__ Special Accommodations If the student currently has an I.E.P., please bring documentation outlining services required.
Recommended to be toilet trained.
~~~~~~
_ Legal Guardianship Original Custody court document must be signed and sealed by a Judge.
Note: “Guardian” means a person to whom a court of competent jurisdiction has awarded guardianship or custody of a child, provided that a residential custody order shall entitle a child to attend school in the residential custodian’s school district subject to a rebuttable presumption that the child is actually living with such custodian; it also means the Department of Children and Family’s for purposes of N.J.S.A. 18A: 38-‐1(e)
Union City Board of Education "INTERNET" Public School Student Registration Information Form
Student information:
It is very important that you take the time to write clearly and legibly in ink. tlPre-k through 5
(Last):__________ (First)_________ (Middle I.) __ Address: _____________ City: .,--:::--------State: __ _
Telephone: and Cell:----==------:--------DateofBirth: __ / __ 1__ Sex: M F Age: __ Birthplace: Country: State: _____ City: _____ _
Previous school information:
Has your child ever attended school iu Union City? __ Yes __ No (If Yes) Please fill out below. Name of School: Grade Attended: ___ Year: ___ _
Previous school name: Name:------------=----- Grade: Attending: __ (Finished) __ _ Address: __________ City:----==---- State: Zip Code: ___ _ Phone: __________ ext.:____ Fax: __________ _
Name of person enrolling student:----=-------- Relationship to student: _____ _ Native Language of person enrolling student: _______ _ How long have you lived at this address? (Month/s_ Day/s_ Year/s__)
Parent information: Mother:
Name: (Last): (First): _______ (Maiden):-------Date of birth: __ /_/_ Place of birth: If deceased state year: __ _ Address: City: State: ---Telephone: __________ and Cell: _________ _
Father:
Name: (Last):-----,--.,...---=-----:-:-:--::--- (First): ----:c;:-;----:--,-----Date of birth: __ /_/_ Place of birth:_______ If deceased state year: __ _ Address: --------------,:-:::-City: ________ State: ___ _ Telephone: and Cell: ___________ _
Name of Sibling: ____________ School Attending: _________ Age: __ Name of Sibling: School Attending: Age: __
Who has legal custody of the student/s: _Mother _Father_ Guardian
If you are the legal Guardian of the student, you have to provide details subsequently requested. Submit all original court credentials from a United States Court with the original court seal and a signature of a Judge.
Legal Guardian in(omwtion:
Name: (Last):-----------:::: (First): _______ _ Address: City: _________ State:
(Middle Initial) __
Telephone: and Cell: ___________ _
*Does the student need any Accommodations? __ NO_ YES (If YES) must provide documentation
Signature of Parent/Guardian:-------------- Date: ______ _
All students age 5 to teen must be present with a parent or /ego/ guardian to register!
·Union City Board of Education Office of Technology
3912 Bergen T=pike Union City; NJ 07087
(201) 348-5770
Student Data Collection
Please fill out this c:fata collective survey. Your cooperation is very much appreciated. (This survey is required/mandated by the New Jersey State department of Education and must be completed by all Union CHy students. This survey my affect future school funding.) · ·
Student's Last Name:-------------------------
Student's First Name:-:----------------------.,..---
Student's Middle Name:-----------------------
City and State of Birth:----------------------
City and Country of Birth:-----------------------
Ethnicity: (please circle) Hispanic/Latina: Yes or No
(Please answer YIES if student is of Cuban, Mexican, Puerto Rican, South or Central American,
or-other Spanish Culture/origin, regardless of race. /Answer NO if not Hispanic or Latino.)-
Race: Please check all that applies.
American Indian or Alaskan Native ------'Asian ___ Black/ African American ___ .Native Hawaiian or Pacific Islander ___ White/Caucasian
Health Information: Date of last Medical Exam: (Date, Month, Year) __ / ! __ Date of last Lead Test: (Date, Month, Year) __ / /_-:-Date of Polio Immunization: (Date, Month, Year) __ / / __
Do you have Health Insurance: Yes or No
If YES, name of Health Insurance Provider:------------------
Union City Public- Schools Office of Bilingual/ ESL Education
HOME LANGUAGE SURVEY '
Please ~wer the following questions:
Student's Name: US. Date of Entry: ____ _
Address: ------------------:-----Telephone: ------
Birth Date: -------- Place of Birth:
Please use only ONE LANGUAGE for each answer.
1. What language ilid your child first leain to speak? ---------,--------------
2. What language do you use most often when speaking to-your child at home? ---------
3. What language does your child use most often when speakil{g to you at home?--------
4. What language does your child use most often when speakin_g to brother( sister? --------
5. What language does your child use most often when speaking to other relatives? --------
6. What language does your child use most often when speaking to friends at home?
ParentJGuardian Signature Date
*****************7********************************************************* Dear Parent or Guardian: As required by State and Federal Law (State Bilingual Education Act of 1975, Federal Lau vs. Nichols Supreme Court ruling of 1974), all parents must be surveyed as to the home language of their public school children.
I We request the above information in order to provide a good instructional program for your child. The completion of this survey is manda1Dry, Thank you for your cooperation.
For office use only: LAU: ___ _ ETH: ----
'k/-;r /s~-::--~r ;
Superintendent of Schools
Grade: ___ _
\
\ "'-
Union City Board Of Education
Central Registration Office
PERMISSION FOR MEDICAL SCREENING
Students Name:------------ _________ Date of Birth: __ ! __ ! __ _
(last) (First) (Month) (Day) (Year)
The following services will be given to all new entrants and only in those grades recommended by the State Department of Education.
Record of Child's Health History
Immunization Evaluation and Completion
Heights and Weights
Blood Pressure (Athletes)
Tuberculin Testing
Vision Screening
Hearing Screening
Scoliosis Screening
Physical Examinations for boys and girls will be done throughout the school year. Boys and girls will be examined separately. In the absence of a parent, a nurse and the teacher, will be present when a student is examined by the School Doctor. Parents are encouraged to attend, if possible.
If you wish to obtain the results of the physical screening, please contact the school nurse. In the event that further examination and/or treatment are necessary, the nurse will be available to inform you.
Please indicate with a check mark:
____ I grant permission for the Union City Board of Education, Medical Department to screen my child.
Signature of Parent/Guardian Date
___ I do not grant permission for the Union City Board of Education, Medical Department to screen my child. I will be responsible to obtain these services by my private Doctor and provide the school nurse with the results.
Signature of Parent/Guardian Date
Our sincerely appreciation for your cooperation in helping us provide the best services for your child.
SUPERINTENDENT OF SCHOOLS
FOR OFFICE USE ONLY
SCHOOL _________________ _ HOME ROOM _____ __
Rev.04/06
------------------------------------------------SCHOOLDISTIUCT
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 iodicated.
CONSENT FOR RELEASE OF INFORMATION TO ACCESS :MEDICAID -REiMBURsEMENT FOR HEALTH RELATED SUPPORT SERVICES
Child'sName: ----~~~------------------~~--~~----------------------------(First) (Mid. Initial) (Last)
Child's Social Security#: ________ / ______ / ___________ _ (If Known)
Child's Medicaid Number: I (If Known)
Child's Date of Birth: _____ ! ______ ! ________ __ (Month) (Date) (Year)
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:
Union City Board of Education Medical Department
3912 Bergen Turnpike Union City, NJ 07087 Tel# 201-271-2289 ext. 1052/1053
Fax# (201) 348-5118
W'"wo,,
;~~~~;~ "ADMINISTRATION OF MEDICATION IN SCHOOL"
School Year: ____ _
Dear Parent or Guardian:
We discourage the administration of medication in the school setting and request that, whenever possible, medications be scheduled during non-school hours. (It is recommentletl the first dose of medication be administered at home.) If your physician has decided it is necessary for your child to receive medication during the school day, it is required that your physician complete the attached document "Instructions/ Physician Order" and the parent bring the orders and medication to the school nurse together. Only the school nurse has the authority to receive medications, do not drop off any medications to any other office.
The medication must in the original bottle with the current prescription label on the container.
The doctor must fill out the attach form completely prior to the school nurse dispensing medication during school hours.
Querido Padre o Guardian:
Aunque noes recomendable administrar medicinas en las escuelas, entendemos que hay excepciones donde es necesario administrar medicinas durante las horas escolares. La enfermera seguini estrictamente las indicaciones de su medico y bajo ninguna circumstancia proveera el servicio a su hijo/a sin una orden actual del doctor. Adjunto a esta carta encontrani un formulario de Instrucciones/Orden de1 Medico que debe completarse y entregarlo en la enfermerfa de Ia escuela.
El medico debe llenar el formulario completamente antes que Ia enfermera de Ia escuela distribuye medicina durante horas escolares.
Le recomendamos que la primera dosis sea administrtula en su cas a.
Name of Student- Nombre del Estudiante
Name of School -Hombre de Ia Escue fa
Gracie-Grado
Name of School Nurse Nombre de Ia Enfermera
Date of birth- Fecha de Nacimiento
School Principal- Director de Ia escuela
Homeroom Aula
Phone number and extension of nurse Numero de Te/efono y extension de enfermeria
I give consent to the school nurse to administer the prescribed medication to my child during school. I also give consent to release this information to appropriate school personnel.
Doy mi consentimiento de que la enfermera de la escuela puede administrar ami hijo!a sus medicamentos7
mientras que este en sesi6n escolar. Toda informaciOn se darii al personal apropiado escolar.
Signature of Parent/Guardian Firma del Padre/Guardian
Date
Print name Parent/Guardian Nombre del Padre/Guardia en letra de molde
Union City Board of Education Medical Department
3912 Bergen Turnpike Union City, NJ 07087 Tel# 201-271-2289 ext. 1052/1053
Fax# {201) 348-5118
Authorization for the School Nurse to Administer Medication
''TO BE COMPLETED BY PHYSICIAN"
INSTRUCTIONS TO ADMINISTER MEDICATION DURING SCHOOL HOURS ONE FORM FOR EACH MEDICATION
Physician's statement:
In order to protect the health of-----,---,----------,-,-,--' it is necessary for the (Student) (DOB)
student have the following medication during school:
DIAGNOSIS: ---------------------------------------------
Name of Medication: _________________________ _
Controlled Substance: YES I NO
Dosage; _____________ _
Route of Administration: __________________ _
Time for Administration~: _________________________ _
Additional Information: _________________________ _
Name of Physician/ Please Print Physician's Signature/Stamp
Address: ____________________ _
Physician Telephone Number: ____________ Date: ____ _
-Page 2 of2-
UNION CITY PUBLIC SCHOOLS PHYSICIAN FORM
TO BE COMPLETED BY THE FAMILY PHYSICIAN AND RETURNED TO SCHOOL PRIOR TO OR ON THE FIRST DAY OF SCHOOL.
0-lndicates Normal
OX- Indicates Abnormal
Child's Name -------'----------------Date of Birth __________ Sex ______ _
Address ______________________ Telephone No.
Height ____________ Weight ________ Blood Pressure _________________ _
General Appearance ---~-~------------Skin __________ .Speech
Teeth _________ Thyroid ___________ Abdomen ___________ Urine _______ _
Nose _________ Thorax Genitalia _________ Rectal _______ _
Throat _________ ,Breast ___________ Hernia ------~----'Nutrition
Tonsils _________ ,Lungs ___________ Extremities
Glands ________ ,Heart ___________ Feet __________ _
Cervical ________ ,Murmur ___________ Scoliosis
Development assessment------~-------------------------------
Neurological assessment
Other disease history ________________________________________ _
History of accidents (dates)
Serious Injury (dates) ________________________________________ _
Taking any Medication Allergic to any Medication ____________________ _
Was child ever hospitilized? D Yes D No If yes, when?
Where? ____________ Why? ___________ Surgical Procedures? ___________ _
VISION: (check one) c glasses
s glasses
HEARING
RIGHT LEFT
___ Acuity
____ Muse. Bat.
Fusion
Plus Lens
1000
FAILURE +-
TB Screening (Mantoux Test)
FAR R L
2000 4000
PASSING IS AT 25 DB
Date: Tested Read Result (MM)
Any reason the child should not take physical training? (If yes, doctor certificate is required).
Remarks:
NEAR R L
5000
Doctor's Signature _______________________ Date _____________ _
Note: Doctor, please attach your prescription blank stating that you have examined the above child and a copy of the immunization record.
M-41 REV. 4/04 (5)
\1Ji:WUIRE.0 M~DlCAL 9£FICE STAMP) @": "R"'E:o,zun;r""·~-""·~·F'E"S""E:F;L,l"'.O"'c"'o""N;:-t,s~u"'t".J""'o"",A_""io""M<7 ...•••• :aED"'J""Cc>:O,.:..,jl
Parental/Guardian Consent Form
We are sending you this parental consent form to both inform you and to request perm1ss1on for your child's photo/image and personally identifiable information to be published on the district and/or school's web site.
As you are aware, there are potential dangers associated with the posting of personally identifiable information on a web site since global access to the Internet does not allow us to control who may access such information. These dangers have always existed; however, we as schools do want to celebrate your child and his/her work. The law requires that we ask for your permission to use information about your child.
Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes student names, photo or image, residential addresses, e-mail address, phone numbers and locations and times of class trips.
If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the principal of your child's school and such rescission will take effect upon receipt by the school.
Check one of the following choices:
0 1/We GRANT permission for a photo/image that includes this student without any other personal identifiers to be published on the school and/or district's public Internet site.
0 1/We GRANT permission for this student's photo/image and name to be published on the school and/or district's public Internet site.
0 1/We GRANT permission for this student's photo/image and all other personal identifiers listed above to be published on the school and/or district's public Internet site.
0 1/We DO NOT GRANT permission for photo/image that includes this student to be published on the school and or district's public Internet site.
Student's Name: (please print) ------------------ Student's Grade: __ _
Print name of Parent/Guardian: (print)---------------------------
Signature of Parent/Guardian: (sign) --------------------------
Relation to Student:--------------------------------
Dffie: __________ __