Lancaster Central School District

149 Central Avenue Debi Mascia

Lancaster, NY 14086 District Registrar

Phone (716) 686-3218 dmascia@lancasterschools.org

Fax (716) 686-3219

Welcome to Lancaster! We are excited to meet you and your incoming kindergarten student! In an

effort to make your start in Lancaster smooth, please read the information below to prepare what is

needed for registration.

Children must be five (5) years old on or before December 1, 2020 to be eligible for all-day

kindergarten in September 2020 in the Lancaster School District.

Kindergarten registration will begin in March and takes place at the K-3 elementary buildings. To

determine your K-3 elementary school, please consult the street list on our website.

https://www.lancasterschools.org/Page/23345.

The K-3 elementary schools will begin taking appointments in February please call to schedule an

appointment. The numbers are listed below.

Documents you must bring to the registration appointment… 2 forms proof of residency – ex. homeowner – binding purchase contract, deed,

mortgage statement, tax bill, utility bill, homeowner insurance rent/lease -- lease agreement, & utility bill or renter insurance If none of above, a Notarized affidavit from property owner with 2 utility bills

Proof of age – ex. Certified birth certificate, baptismal certificate

Custody agreement - (if both parents not in the home)

Immunization Record

Health Appraisal (physical within 1 year)

Dental Health Certificate

Kindergarten screening will take place in May at the K-3 elementary schools

If you are not planning to register your child for kindergarten or if your child will attend a

private/parochial school for kindergarten, please call your school office as soon as possible so we can

update our records. Your child is not required to accompany you for registration.

You need to register with the district if your child will attend a private/parochial school.

The Private/Parochial registration packet is also on the Registrar tab of our website.

Como Park Elementary

1985 Como Park Blvd

Lancaster, NY 14086

Phone: 716-686-3235

Fax: 716-686-3303

Court Street Elementary

91 Court St

Lancaster, NY 14086

Phone: 716-686-3240

Fax: 716-686-3306

Hillview Elementary

11 Pleasantview Dr

Lancaster, NY 14086

Phone: 716-686-3280

Fax: 716-686-3307

John Sciole Elementary

86 Alys Dr

Depew, NY 14043

Phone: 716-686-3285

Fax: 716-686-3309

Lancaster Central School District Registration Form Page 1/4

LANCASTER CENTRAL SCHOOL DISTRICT STUDENT REGISTRATION FORM (Please print in ink and complete all areas)

NOTICE

Please be advised that the provision of false information on this registration form could constitute a crime. In addition, the District reserves its right to recover from parents, legal guardians or other responsible parties the entire actual cost of educating a student, plus related costs, for the entire period that any non-resident student is enrolled in the District's schools with authorization and/or under false pretenses. The cost of educating a student for the schoolyear ranges from approximately $9,500 elementary to $10,000 secondary.

I HAVE READ AND UNDERSTAND THIS NOTICE.

Signature FOR OFFICE USE ONLY:

ID: SCH: GR: START:

STUDENT INFORMATION

Student’s Last Name:_________________________________ First Name: ____________________________ Middle: ______________

Street Address: ___________________________________________________________________________________________________

City: ________________________ State: ______ Zip Code: _________ Primary Household Phone:____________________________

Gender: Male Female Date of Birth:_______________ City/State of Birth: ____________________________

mm/dd/yyyy

Military Connected Youth: Yes No (Parent/Guardian is on Active Duty, a Member of National Guard/Reserves, or is a

Veteran of United States Military)

RESIDENCE INFORMATION

Residence Type: Own Rent Lease Foster Care Agency Unknown

________________________If rent/lease, name of property owner: ____________________________________________Telephone:

Proof of Residency:

Property Tax Bill House Deed Utility Bill Lease/Rental Agreement Mortgage Statement

Purchase Contract Other than above: _____________________________________________________________________

Previous Address: _____________________________________________________________________________Number of years:

Street Apt. No. City/Town Zip Code

Please list all other properties owned by either parent/guardian:

Street Apt. No. City/Town Zip Code

Street Apt. No. City/Town Zip Code

Please list all other properties rented by either parent/guardian:

Street Apt. No. City/Town Zip Code

Street Apt. No. City/Town Zip Code

Lancaster Central School District Registration Form Page 2/4

SCHOOL HISTORY

Attended LCSD Before? Yes No If YES, previous Enrollment Date: Previous Grade:

If NO, what was the last school attended by this student?

Street City/Town Zip Code Address of school:

Telephone: Grade Last Attended: Present Grade:

Name and address of all schools previously attended: (Including any Lancaster schools ever attended)

*For UPK or K grade registration list pre-schools or daycares previously attended

Name of School Address Dates Attended Grades

Name of School Address Dates Attended Grades

Name of School Address Dates Attended Grades

Was the student suspended or removed from a school the student attended? Yes

If yes, explain:

Proof of Age: Birth Certificate Baptismal Certificate Passport OR Other, specify

Is your child currently receiving Special Education Services? ____ YES ____ NO

If YES, what is your child's classification:

List Services/Programs:

Is your child currently receiving Section 504 accommodations? ____YES ____NO

Is your child currently receiving other Academic Support Services (Title 1 Reading or Math?) ____YES ____ NO

If YES, please list services:

HEALTH INFORMATION

Physician’s Name: Telephone:

Please describe any conditions or requirements of which the District should be aware? (Food allergies, asthma, medications, etc.)

N O

Lancaster Central School District Registration Form Page 3/4

PARENT / GUARDIAN INFORMATION

PARENT/GUARDIAN # 1 (Note: Parent/Guardian #1 must reside at the same address as that indicated for the student.)

NAME: ___________________________________________________________________________________ Last First MI

Address: Street Apt. No. City/Town Zip Code

Relationship to student:

Indicate calling order: 1 – 2 – 3

#____Home telephone: ____________________ #____Work: ___________________ #____Cell: ______________________

Email Address: ____________________________________________________________________________________________________________

PARENT/GUARDIAN # 2

NAME: _____________________________________________________________________________________________________ Last First MI

Does Parent/Guardian reside in household? YES NO (If NO, provide Address and Home Telephone number)

Address

Street Apt. No. City/Town Zip Code

Relationship to student: __________________________

Indicate calling order: 1 – 2 – 3

#____Home telephone:__________________ #_____ Work: ___________________ #____ Cell: _______________________

Email Address:

SIBLING INFORMATION

NAME OF SIBLINGS (under age 21) (Address if different from household)

BIRTH DATE

mm/dd/yyyy

GENDER GRADE SCHOOL CURRENTLY

ATTENDS

Lancaster Central School District Registration Form Page 4/4

EMERGENCY CONTACT INFORMATION

In the event a parent/guardian cannot be reached, the following may be contacted.

1. Name:___________________________________________ Relationship to student: _________________________

Indicate calling order: 1 – 2 – 3

#____Home telephone:___________________ # Work _____________________ # Cell: _______________________

2. Name: Relationship to student: _________________________

Indicate calling order: 1 – 2 – 3

#____Home telephone:___________________ #____ Work: ____________________ # Cell: _______________________

CONFIDENTIAL INFORMATION

YES NO Awaiting foster care (through the Department of Children and Family or Social Services) placement?

Living in a car, park, bus or train station? YES NO

Living in an abandoned building or similar substandard housing? YES NO

CERTIFICATION AND AUTHORIZATION

I hereby certify that the student listed on this registration form actually resides at the address specified on Page 1 within the Lancaster School District boundaries. I further certify that all the information I provided on this registration form is true and correct. I understand that I must immediately notify the District if the residency of the student changes from the address listed on this registration form.

I authorize the request of student records from previous schools and give permission to the Lancaster Central School District to verify telephone numbers and addresses. I understand that if the district believes that the information on this form is no longer correct or that the child being registered no longer lives at the address provided, the Lancaster Central School District has the right under New York State Law to investigate and to withdraw the child from the Lancaster Central School District.

SIGNATURE MUST BE WITNESSED BY REGISTRAR

Parent/Guardian Name:

(Please Print)

Parent/Guardian Signature ________________________________________________ Date:

Please print completed form using Print icon on toolbar.

Updated January 2020

(Your answers will help school staff determine if the student is eligible to receive additional services)

Is the student listed on this registration form:

Sharing the housing of other person due to loss of housing, economic hardship or similar reason? YES NO

Living in a motel/hotel, trailer park or camping ground? YES NO

Living in an emergency or transitional shelter? YES NO

Teacher:___________________________________ Grade: _______

HEALTH QUESTIONNAIRE & EMERGENCY FORM PUPIL PERSONNEL SERVICES - LANCASTER CENTRAL SCHOOLS

** PLEASE RETURN TO THE SCHOOL NURSE ** DATE: ______________________

STUDENT NAME: _____________________________________________________ MALE: _____ FEMALE: __________ LAST FIRST MIDDLE

ADDRESS: ________________________________________________ CITY: ______________ ZIP: _________________

HOME PHONE: __________________________BIRTH DATE & PLACE: ________________________________________

#1 PARENT #2 PARENT

GUARDIAN NAME: _______________________________ GUARDIAN NAME: _________________________________

PLACE OF BUSINESS: _____________________________ PLACE OF BUSINESS: _______________________________

HOURS & WORK PHONE: __________________________ HOURS & WORK PHONE: ____________________________ CELL PHONE: ____________________________________ CELL PHONE: ______________________________________

E-MAIL: __________________________________________ E-MAIL:____________________________________________

*PLEASE INDICATE THE ORDER IN WHICH YOU WOULD LIKE CONTACT TO BE MADE. THE ORDER OF

CONTACT(S) ON THIS SHEET SHOULD CORRESPOND TO THOSE LISTED IN ESCHOOL.

IF PARENTS ARE NOT AVAILABLE, IN CASE OF EMERGENCY PLEASE CONTACT

1. NAME: ______________________________________________ RELATIONSHIP: ____________________________________________________

ADDRESS: ____________________________________________________________________ PHONE:____________________________________

2. NAME: ______________________________________________ RELATIONSHIP: ____________________________________________________

ADDRESS: ____________________________________________________________________ PHONE:____________________________________

3 . NAME: ______________________________________________ RELATIONSHIP: ____________________________________________________

ADDRESS: ____________________________________________________________________ PHONE:____________________________________

HEALTH HISTORY HAS ANYTHING MEDICALLY CHANGED WITH YOUR CHILD? IF YES, PLEASE EXPLAIN AND PROVIDE MEDICAL

DOCUMENTATION FROM YOUR PHYSICIAN: ___________________________________________________________ ______________________________________________________________________________________________________________

Please note if any of the following conditions pertain to your child:

ANEMIA _________________________________________ PNEUMONIA ______________________________ KIDNEY CONDITIONS _________________

ASTHMA/REACTIVE AIRWAY _____________________ NEUROLOGICAL CONDITION _________________ MONONUCLEOSIS ____________________

RHEUMATIC FEVER _____________________________ TUBERCULOSIS ______________________________ MIGRAINE/HEADACHES_______________

CHRONIC RESPIRATORY PROBLEMS _____________ SEIZURE DISORDER __________________________ HEART DISEASE ______________________

DIABETES _______________________________________ SURGERIES _____________________________________________________________________

EAR CONDITIONS ________________________________ INJURIES/FRACTURES _______________________________________________________________

DETAILS: _____________________________ ALLERGIES: ______________________________ REGULAR MEDICATIONS: (LIST ONLY) ______________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

NAME OF PEDIATRICIAN: ______________________________________ PHONE: _______________________

I understand that this information may be shared with personnel involved with my child.: ____________________________________

(Parent’s signature)) 1/19jw

Dental Health Certificate Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 1,3,5,7,9,11. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.

Section 1. To be completed by Parent or Guardian (Please Print)

Child’s Name: Last First Middle

Birth Date: / / Month Day Year

Sex: Male

Female Will this be your child’s first visit to a dentist? Yes No

School: Name Grade:

Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No

I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health.

I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below.

Parent’s Signature:______________________________________________________________ Date: ____________________

Section 2. To be completed by the Dentist

The Dental Health condition of __________________________________ on _________________ (date of exam) The date of the exam needs to be within 12 months of the start of the school year in which it is requested.

Check one:

Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.

No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.

NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.

Dentist’s name and address (please print or stamp) Dentist’s Signature

Optional Sections - If you agree to release this information to your child’s school, please initial here.:________

II. Oral Health Status (check all that apply).

Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].

Yes No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].

Yes No Dental Sealants Present

Other problems (Specify): ______________________________________________________________________________

III. Treatment Needs (check all that apply)

No obvious problem. Routine dental care is recommended. Visit your dentist regularly.

May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.

Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

LANCASTER CENTRAL SCHOOL DISTRICT

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5/1/2018 Page 1 of 2

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR

Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or

Committee on Pre-School Special education (CPSE).

STUDENT INFORMATION

Name: Sex: M F DOB:

School: Grade: Exam Date:

HEALTH HISTORY

Allergies ☐ No

☐ Yes, indicate type

☐Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached

☐ Food ☐ Insects ☐ Latex ☐Medication ☐ Environmental

Asthma ☐No

☐ Yes, indicate type

☐Medication/Treatment Order Attached ☐ Asthma Care Plan Attached

☐ Intermittent ☐ Persistent ☐ Other : ___________________________

Seizures ☐ No ☐Medication/Treatment Order Attached ☐ Seizure Care Plan Attached

☐ Yes, indicate type ☐ Type: __________________________ Date of last seizure: ______________

Diabetes ☐ No ☐Medication/Treatment Order Attached ☐ Diabetes Medical Mgmt. Plan Attached

☐ Yes, indicate type ☐Type 1 ☐ Type 2 ☐ HgbA1c results: ____________ Date Drawn: _____________

Risk Factors for Diabetes or Pre-Diabetes: Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.

BMI____________kg/m2 Percentile (Weight Status Category): <5th 5th-49th 50th-84th 85th-94th 95th-98th 99th and<

Hyperlipidemia: ☐ No ☐ Yes Hypertension: ☐ No ☐ Yes

PHYSICAL EXAMINATION/ASSESSMENT

Height: Weight: BP: Pulse: Respirations:

TESTS Positive Negative Date Other Pertinent Medical Concerns

PPD/ PRN ☐ ☐ One Functioning: ☐ Eye ☐ Kidney ☐ Testicle

Sickle Cell Screen/PRN ☐ ☐ ☐ Concussion – Last Occurrence: __________________________

Lead Level Required Grades Pre- K & K Date ☐Mental Health: ________________________________

☐ Other:☐ Test Done ☐ Lead Elevated > 10 µg/dL

☐ System Review and Exam Entirely Normal

Check Any Assessment Boxes Outside Normal Limits And Note Below Under Abnormalities

☐ HEENT ☐ Lymph nodes ☐ Abdomen ☐ Extremities ☐ Speech

☐ Dental ☐ Cardiovascular ☐ Back/Spine ☐ Skin ☐ Social Emotional

☐ Neck ☐ Lungs ☐ Genitourinary ☐ Neurological ☐Musculoskeletal

☐ Assessment/Abnormalities Noted/Recommendations: Diagnoses/Problems (list) ICD-10 Code

_________________________ _____________

_________________________ _____________

_________________________ _____________

☐ Additional Information Attached _________________________ _____________

5/1/2018 Page 2 of 2

Name: DOB:

SCREENINGS

Vision Right Left Referral Notes

Distance Acuity 20/ 20/ ☐ Yes ☐ No

Distance Acuity With Lenses 20/ 20/

Vision – Near Vision 20/ 20/

Vision – Color ☐ Pass ☐ Fail

Hearing Right dB Left dB Referral

Pure Tone Screening ☐ Yes ☐ No

Scoliosis Required for boys grade 9 Negative Positive Referral

And girls grades 5 & 7 ☐ ☐ ☐ Yes ☐ No

Deviation Degree: Trunk Rotation Angle:

Recommendations:

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

☐ Full Activity without restrictions including Physical Education and Athletics.

☐ Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications

☐ No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling

☐ No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, skiing, swimming and diving, tennis, and track & field

☐ Other Restrictions:

☐ Developmental Stage for Athletic Placement Process ONLY

Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports

Student is at Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V

☐ Accommodations: Use additional space below to explain

☐ Brace*/Orthotic ☐ Colostomy Appliance* ☐ Hearing Aids

☐ Insulin Pump/Insulin Sensor* ☐Medical/Prosthetic Device* ☐ Pacemaker/Defibrillator*

☐ Protective Equipment ☐ Sport Safety Goggles ☐ Other:*Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.

Explain: _____________________________________________________________________________

MEDICATIONS

☐Order Form for Medication(s) Needed at School attached

List medications taken at home:

IMMUNIZATIONS

☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No

HEALTH CARE PROVIDER

Medical Provider Signature: Date:

Provider Name: (please print) Stamp:

Provider Address:

Phone:

Fax:

Please Return This Form To Your Child’s School When Entirely Completed.

Lancaster Central School District 177 Central Avenue Andrew P. Kufel, Ph. D. Lancaster, NY 14086 Assistant Superintendent for Curriculum, Phone: (716) 686-3206 Instruction & Pupil Services Fax: (716) 686-3316

CODE RED EMERGENCY NOTIFICATION SYSTEM

I am aware that Lancaster Central School District has subscribed to an alert system known as

Code RED. The Lancaster Central School District may use the alert system to communicate

with the public in cases where prompt notice to protect life, health or property is advantageous.

I acknowledge the alert system known as Code RED by the Lancaster Central School District is

provided as a service to families of Lancaster Central School District.

As such, Lancaster Central School District, its officers, agents and employees enjoy immunity

when providing the Code RED alert system services.

By signing this release, I waive all claims against Lancaster Central School District and Code

Red, their officers, agents and employees in the event that members of my household, my

property or myself are adversely affected in the absence of timely notice of any event.

Please Note: The numbers called by the Code RED alert system are pulled from the registration

information you provided on the registration form. The numbers pulled from the registration

form are:

1. Household phone number

2. Guardian #1 Cell phone number

3. Guardian #1 Work phone number

4. Guardian #2 Cell phone number

These phone numbers can also be updated by parents through the parent portal or by contacting

the registration office at 686-3218. A link to the parent portal is available on the district webpage

at http://www.lancasterschools.org.

_________________________________________

Student Name

_________________________________________ _____________________

Signature Date

Jan 2019

LANCASTER CENTRAL SCHOOL DISTRICT 177 Central Avenue

Lancaster, NY 14086

HEALTH INSURANCE ASSESSMENT

My child needs health insurance:

No, my child already has health insurance.

Yes, I would like more information.

IT’S EASIER THAN EVER TO APPLY FOR HEALTH INSURANCE

Free or low-cost health insurance is now available for all children and teens in New York through Child Health Plus.

Please complete this form if you would like to receive more information. We will be offering a seminar to assist in the enrollment process each fall, and at various times throughout the school year. Enrollment assistance is also available on an individual basis. If you have any questions please contact Anne Monin, Lancaster Family Support Center Coordinator, at 686-3806.

Parent Name: _________________________________________________________

Student Name(s) _________________________________________________________

_________________________________________________________

Address: _________________________________________________________

__________________________________________________________

Telephone: ___________________________________________________________

Best Time to Reach You: Daytime: _____ Evenings: _____ Weekends: _____

Please Read and Sign

“I agree to having the information on this referral form shared with facilitated enrollment organizations providing application assistance for Child Health Plus, Medicaid and Family Health Plus. I understand this information is being shared with facilitated enrollment organizations so that they may contact me or members of my family about applying for Child Health Plus, Medicaid or Family Health Plus.”

Signature: _________________________________________ Date: _____________

Please return to the School Nurse or the Lancaster Family Support Center at Lancaster Middle School

Lancaster Central School DistrictCommittee on Special Education

177 Central AvenueLancaster, NY 14086 ((716) 686-3215)

Medicaid Consent

This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's individualized education program (IEP).

This consent allows the school district to bill for covered health-related services and to release information to the school district’s Medicaid Billing Agent for that purpose.

I, _________________________________as the parent/guardian of ___________________ , have received a written notification from the school district that explains my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services.

I understand and agree that the School District may access Medicaid to pay for special education and related services provided to my child.

I understand that: Providing consent will not impact my child’s/my Medicaid coverage; Upon request, I may review copies of records disclosed pursuant to this authorization; Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid; I have the right to withdraw consent at any time; and The school district must give me annual written notification of my rights regarding this consent.

I also give my consent for the school district to release the following records/information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared.

Records to be shared (such as records or information about services your child receives)IEP Medication Administration ReportWritten Order/Referral Special Transportation LogEvaluation Reports Other Personally Identifiable InformationSession Notes Any Other Specific Records Pertaining to the Student’s Services

or Program

I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.

Student Name: ____________________________________Client Identification Number (CIN): ________________ Parent/Guardian Signature: __________________________________________

Print Name: __________________________________________ Date: ____________________

PLEASE RETURN TO SPECIAL EDUCATION OFFICE

Revised 7/11/17

Thank you for completing the forms necessary to

register your child for school in Lancaster.

In an effort to save you time, we ask that you fill out the

following forms prior to your appointment, so the school

district can collect them immediately after your child’s

registration is complete.

The following forms are not part of the registration process;

the school district will not ask for them prior to completing

the registration process. Please do not present them to the

school official until after your child is registered. Your

answers to the questions on these forms have no bearing on

your ability to register your child for school.

Thank you.

1 ENGLISH

Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.

STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12

Lissette Colon-Collins, Assistant Commissioner

Office of Bilingual Education and World Languages

55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB

Brooklyn, New York 11217 Albany, New York 12234

Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948

Home Language Questionnaire (HLQ)

H O M E L A N G U A G E C O D E

Language Background (Please check all that apply.)

1. What language(s) is(are) spoken in the student’s home or residence?

English Other

specify

2. What was the first language your child learned? English Other _________________________________________

specify

3. What is the Home Language of each parent/guardian? Mother Father

specify specify

Guardian(s) specify

4. What language(s) does your child understand? English Other

specify

5. What language(s) does your child speak? English Other Does not speak

specify

6. What language(s) does your child read? English Other Does not read

specify

7. What language(s) does your child write? English Other Does not write

specify

TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::

Please write clearly when completing this section. S T U D E N T N A M E :

First Middle Last

D A T E O F B I R T H : G E N D E R :

Male Female Month Day Year

P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :

Last Name First Name Relation to Student

S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T

I N F O R M A T I O N S Y S T E M :

District Name (Number) & School Address

2 ENGLISH

Home Language Questionnaire (HLQ)—Page Two

Relationship to student: Mother Father Other:

Educational History

8. Indicate the total number of years that your child has been enrolled in school _____________

9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write in English or any other language? If yes, please describe them.

Yes* No Not sure *If yes, please explain:____________________________________________________________________________ How severe do you think these difficulties are? Minor Somewhat severe Very severe

10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below

10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .

Age at which services received (Please check all that apply):

Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)

10c. Does your child have an Individualized Education Program (IEP)? No Yes

11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

12. In what language(s) would you like to receive information from the school? _________________________________________________

Month: Day: Year:

Signature of Parent or of Person in Parental Relation Date

OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ NAME: POSITION:

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:

NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW

NAME: POSITION:

ORAL INTERVIEW NECESSARY: NO YES

**DATE OF INDIVIDUAL

INTERVIEW:

OUTCOME OF

INDIVIDUAL

INTERVIEW:

ADMINISTER NYSITELL

ENGLISH PROFICIENT

REFER TO LANGUAGE PROFICIENCY TEAM MO DAY YR.

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL

NAME: POSITION:

DATE OF NYSITELL

ADMINISTRATION:

PROFICIENCY LEVEL

ACHIEVED ON

NYSITELL: ENTERING EMERGING TRANSITIONING EXPANDING COMMANDING

MO. DAY YR.

FOR STUDENTS WITH DISABILITIES, LIST ACCOMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:

Revised Jan 2019

LANCASTER CENTRAL SCHOOL DISTRICT

STUDENT RACIAL-ETHNIC-LANGUAGE IDENTIFICATION

All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition or immigration status.

Name of School: __________________________________________ Grade: __________________ District Student ID Number: _________________________________ Date of Birth: ___________________ (month/day/year)

Student Name: _________________________________________________________ (Last) (First) (MI)

PLEASE READ CAREFULLY AND ANSWER ALL QUESTIONS.

1. Is the student Hispanic, Latino, or of Spanish origin? (Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South

American, or other Spanish culture or origin, regardless of race.)

Please check ( ) the box that best describes your child. Check ( ) only ONE box.

YES, Hispanic

NO, not Hispanic

2. Select one or more races from the following five racial groups.

Please check ( ) all groups that apply to your child; check ( ) at least ONE box.

AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of

North America and who maintains cultural identification through tribal affiliation or community recognition.

e.g., Cherokee, Mohawk, Inuit.) ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian

subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine

Islands, Thailand, and Vietnam. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original

peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

BLACK: A person having origins in any of the black racial groups of Africa.

WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

3. What are the languages spoken at home? ____________________________________________ .

Does the student understand English? YES NO

What language does the student: read? ________________ write? ______________speak? ______________

X _____________________________________________________ ________________________ (Signature of Parent/Guardian/Other) (Date)

Relationship to Student (please check box below): Mother Father Guardian Other (specify): ______________________________