REGISTRATION FORM INSTRUCTIONS

STUDENT INFORMATION: (Please fill in all blanks on the registration form.)

Preferred Name:

Is the name the student prefers to be address by

Special Education and Individual Education Plan:

Check Y/N if the student received Special Education Services and has an Individual Education Plan.

Mailing Address:

(If different) might be a post office box or another address where parents/guardians prefer mailing to be sent.

Student Lives With:

May be Parents, Father, Mother, Brother, Sister, etc...

PARENT/GUARDIAN INFORMATION: (Please fill in all blanks on the registration form.)

Contact 1: May be either parent or guardian.

Title: May be Mr., Mrs., Ms., Dr., etc.

Residence Address: Is filled in only if is different from the student address

Contact 2: Is the other parent or guardian, if applicable

EMERGENCY CONTACTS:

Contacts 1 & 2 should be local contacts in case of emergency or early dismissal from school

HOME LANGUAGE SURVEY:

This information is used to determine eligibility for English as a Second Language (ESL) services

ETHNIC BACKGROUND:

Required by Federal Law.

TRANSCRIPT RELEASE FORM:

Completion is required in order to receive the necessary records from your child’s previous school.

**AFTER ALL INFORMATION IS FILLED IN, PLEASE RETURN THE REGISTRATION FORM FOR

REVIEW BY THE REGISTRATION CLERK. **

THE FOLLOWING DOCUMENTATION IS REQUIRED FOR REGISTRATION.

1. Official Birth Certificate

2. Up to date Immunization Records

3. Proof of Residency ~ 2 forms are required. Please see following page for acceptable documents.

All documents must be current

4. Court Order if Guardian, or any court documentation pertaining to the child.

SCHOOL ADMISSIONS

Any child qualified for admission to the Bristol Warren Regional School District may at any time be admitted to school by

completing the established admissions and residency protocols.

In order to establish residency for the purpose of enrolling students in the Bristol Warren Regional School

District, you must provide two current sources of residency verification; one primary source from list A and one

secondary source from list B.

You may use list C only if it is determined that you are unable to provide the items listed in both A. and B.

A. Primary:

Mortgage Statement or

Real Estate Tax Bill or

Formal Lease (signed by both parties) or

Notarized Letter from Landlord including current date, name of landlord, name of tenant/s and

address

(must be accompanied by RE Tax Bill or Mortgage Statement in Landlord’s name).

B. Secondary: Household Utility Bill

Gas or

Water or

Electric or

Oil

C. Affidavit of Residency: (only if unable to use options A and B) must provide all three documents

a. Notarized Affidavit of Residency by Parent – (cannot be notarized by an employee of the Bristol

Warren Regional School District)

b. Notarized Affidavit of Residency by Resident – (cannot be notarized by an employee of the Bristol

Warren Regional School District)

c. One item from either A or B in resident’s name

The school department will conduct registration of students who plan to enter Bristol Warren Regional School District for

the first time during the spring preceding the school year of admission.

ADOPTED: January 24, 1994

Revised: July 16, 2007

December 9, 2013

LEGAL REF.: 16-38-2

16-64-1 http://webserver.rilin.state.ri.us/Statutes/title16/16-38/16-38-2.htm http://webserver.rilin.state.ri.us/Statutes/title16/16-64/16-64-1.htm

CROSS REF.: JEB, Entrance Age

JECA/JECB, Admission of Resident/Nonresident Students JHCB, Inoculation of Students

School Year:__________________ Date of Application: ___________________________

BRISTOL WARREN REGIONAL SCHOOLS – REGISTRATION FORM

STUDENT INFORMATION:

Last Name First Name Middle Initial Preferred Name

Yes No Yes No

Grade Gender Date of Birth Special Education Individual Education Plan

Date of entry into USA (if not born in USA) _______________

STUDENT RESIDENCE:

(401) -

Number / Street Apt. # City State Zip Home Phone

Student lives with: _________________________________________ Student Mailing Address (if different) ____________________________________________

Mother’s Email Address: ________________________________________ Father’s Email Address: ______________________________________________

Other children in family _______age _______age _______age _______age

PARENT / GUARDIAN INFORMATION:

Contact 1:

Relationship to student Title Last Name First Name Middle Initial

(401) -

Number / Street Apt. # City State Zip Phone cell / home (circle one)

(401) -

Employer Employer Address City State Zip Work Phone

Contact 2:

Relationship to student Title Last Name First Name Middle Initial

(401) -

Number / Street Apt. # City State Zip Phone cell / home (circle one)

(401) -

Employer Employer Address City State Zip Phone

Please provide two local contacts if we are unable to reach parent or guardian or in case of an early dismissal:

Emergency Contact 1:

Relationship to student Title Last Name First Name Middle Initial

(401) -

Number / Street Apt. # City State Zip Phone cell/ home (circle one)

Emergency Contact 2:

Relationship to student Title Last Name First Name Middle Initial

(401) -

Number / Street Apt. # City State Zip Phone cell / home (circle one)

(401) -

Student Doctor’s Name Doctor’s Address City State Zip Phone

Has your child ever attended Bristol Warren School? Yes No If yes where ___________________Years_____________________

School transferring from: _______________________________________________________________

RACE ETHNICITY DATA COLLECTION

In accordance with new race and ethnicity guidelines from the U.S. Department of Education, please respond to BOTH of the following questions:

1. Is this child or student (or Are you) Hispanic / Latino? (Choose only one of the following):

No, Not Hispanic / Latino

Yes, Hispanic / Latino (A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or

origin, regardless of race.

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking

one or more boxes to indicate what you consider your child or student’s (or your) race to be.

2. What is the child or student’s (or your) race? (Choose one or more from below)

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America (including

Central America,), and who maintains tribal affiliation

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 Island, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups or Africa.

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other

Pacific Islands.

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

Signature of Adult Relationship to Student Date

Subscribed and Sworn to pursuant to Rhode Island General Laws this to Rhode Island General Laws this ________________________day of ________________________

____________________________________________________________

Notary Public

Print Name of Notary ____________________________________________________________

Address of Notary ____________________________________________________________

***************************************************************************************************************************

OFFICE USE ONLY ( NO REGISTRATION IF THIS FORM IS NOT COMPLETED)

Y / N Y / N Y / N / / Y / N

Birth Certificate Immunization Verified Residency Confirmed Residency Document Area Confirmed

/ / / / / / Y / N

Start Date ID# Siblings – School Transcript Requested Home School

/ / /

School No. Homeroom District

The aforementioned student must be a legal resident of Bristol Warren. Proof of residency may include lease agreement, tax, bill, utility bill or any

combination as required by the School Department.

The undersigned herby certifies that this student is legally residing permanently with me at the aforementioned address and is not merely in residence only to attend school in Bristol Warren. Should student’s address change at any time, I will immediately notify the Bristol Warren Public Schools.

I understand that should student fraudulently register for school or become a non-resident and remain in school, I will be personally responsible for the payment

of tuition at the prevailing rate. Pursuant to the Rhode Island General Laws section 11-18-1 (false documents, and Section 11-33-1 (perjury), I certify that the provided information is true and

may be relied upon in enrollment in the Bristol Warren Public Schools at public expense.

11-18-1 GIVING FALSE DOCUMENT TO AGENT, EMPLOYEE, OR PUBLIC OFFICIAL .. No person shall knowingly give to any agent, employee, or servant in public or private employ, or public official any receipt, account, or other document in respect of which the principal, master, or employer

particular, and which, to his knowledge, is intended to mislead the principal, master, employer, or state, city, or town of which he is an official. Any

person who violates any of the provisions of the section shall be deemed guilty of a misdemeanor, and shall, on conviction thereof, be imprisoned, with or without bard labor, for a term not exceeding one (1) year, or be fined not exceeding one thousand dollars ($1000).

173 PERJURY AND FALSE SWEARING 11-33-1. PERJURY. Every person of whom an oath or affirmation is or shall be required by law, who shall willfully

swear or affirm falsely in regard to any matter or thing respecting which such oath or affirmation is or shall be required, shall be deemed guilty of perjury.

(Seal)

Bristol Warren Regional School District

151 State Street, Bristol, RI 02809-2205

LANGUAGE SURVEY FORM

The cultural composition of our community is one of our major assets. Language is a major means of cultural expressions. Accordingly, we are attempting

to identify the cultural resources we have in our community. This questionnaire will help us in determining the home language of all students and also

assist us in providing each student with the most appropriate educational program.

__________________________________ _____________________________ _______ ________

LAST NAME FIRST NAME M.I. GRADE

1. What Languages are spoken in your home? English ________ Other ________

2. Which Language did your child learn when he/she first began to talk? English ________ Other ________

3. What Language do you use most frequently when speaking to your child? English ________ Other ________

4. What Language does your child use most frequently when speaking to you? English ________ Other ________

5. What Language does you child use most frequently when speaking to others? English ________ Other ________

6. If your child is cared for by another person on a regular basis, what language English ________ Other ________

is most frequently used?

7. In what Language do you prefer communications be sent home? English ________ Other ________

STUDENT INFORMATION

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you

complete the following information regarding you child. Your cooperation is appreciated.

Student Social Security Number: _________________________ (Check one): Male______ Female ______

Check one of the following Race / Ethnic Groups:

____Hispanic ____Black ____White ____American Indian / Alaskan Native ____Asian / Pacific Islander

Date:_________________________ Signature of Parent/Guardian _____________________________________

The Bristol Warren Regional School District does not discriminate on the basis of age, sex, race, religion, national origin, color, disability or

sexual orientation in accordance with applicable laws and regulations.

Rev. 2-2003

Authorization for Release of Information to

Bristol Warren Regional School District

I herby authorize the _________________________________________________________

(School Name & Address)

to release the following information from the record of: _______________________________ (Name of Student)

to the Bristol Warren Regional School District.

Date of Birth: _____/_____/_____ Last Grade Attended: __________

Signature of Parent / Guardian Date

REQUESTED INFORMATION:

Cumulative Folder _________

Health Record _________

Attendance Record _________

Copy of Latest Report Card _________

Educational Testing Results _________

Individual Educational Plan (IEP) _________

Remedial/Chapter 1 Services _________

Other (Please specify) _________

Please send information to:

Kickemuit Middle School

Attn: Bethanie Maduro-Antonio

525 Child Street

Warren, RI 02885

**Parental permission is no longer required when records are requested by authorized personnel.**

(Family Educational Right and Privacy Act, Final Rule on Educational Records. Federal Register, June 17, 1976, Vol. 41, No. 118,

page 24673).

Bristol Warren Regional School District 151 State Street, Bristol, RI 02809 Tel. 401-253-4000 Fax. 401-253-0829

Leslie J. Anderson, M.Ed., Director

Office of Pupil Personnel Services Release of Information

Student Name: ______________________________________ Date of Birth:_________________ Student is (please check one) ____entering ____leaving ____currently enrolled at: ____________________

I hereby authorize Bristol Warren Regional School District Pupil Personnel Office to:

Obtain From: Release To:

Name: _______________________________ Name: _______________________________

Address: _____________________________ Address: _____________________________

_____________________________ _____________________________

Tel: _________________________________ Tel: _________________________________

Fax: _________________________________ Fax: _________________________________

Give/Receive by: ______Mail ______Fax ______in person/telephone ______any/all

Psychological____ Speech/Language____ Occupational Therapy____

Social ____ Medical ____ Physical Therapy ____

Psychiatric ____ Educational ____ I.E.P. ____

Vocational ____ FBA ____ Adapted Behavior ____

Other:_______________________________________________________________________

For the purpose of: _____Educational Planning or Other:___________________________

Any information received shall not be further relayed to any other source without written consent.* I hereby release the Bristol Warren Regional School District and its duly authorized agents from all legal responsibility for the release of information indicated and authorized herein.

Signed: _________________________________ Date: _____________________

Print Name: __________________________________________________________

Relationship to student: _____________________ Contact Tel: ________________

*Consent means that the parent/guardian has been fully informed of all information relevant to the activity for which consent is sought, his or her native language, or other mode of communication. The parent understands and agrees in writing to the carrying out of the activity for which his or her consent is sought, and the consent describes that activity and lists the records (of any that will be released and to whom,) and the parent understands that the grant of consent is voluntary on the part of the parent and may be revoked at any time.

Kickemuit Middle School

525 Child Street

Warren, RI 02885

Tel. 401-245-2010

Fax 254-5960

Medication Consent for administration of:

Acetaminophen (generic Tylenol)

Ibuprofen (generic Advil/Motrin)

Antacid: Tums, Maalox or Mylanta

● In order for the above medication to be given to students for minor complaints at Kickemuit Middle

School, this form must be signed by parent or guardian.

● Should the school nurse consider the number of requests for medication to be excessive, the parent or

guardian will be contacted and will recommend medical evaluation for complaints.

● This permission will remain in effect for their tenure at Kickemuit Middle School or until it is withdrawn

in writing or the student leaves the school system.

● Administration of any other medication at school requires a written physician's order and parent signature.

● Medication Authorizations Forms can be obtained on the district website on the Parents page,

http://www.bwrsd.org/pages/Bristol_Warren_Regional_School/Parents

● Look for “Information and Forms” on the left hand side of page. Scroll down and you will see link

entitled “Physician and Parent Medication Consent Form”.

http://www.bwrsd.org/files/_tVK1c_/079533323f02daef3745a49013852ec4/Physician_and_Parent_Medic

ation_Consent_Form.pdf

I grant permission for the administration of acetaminophen, ibuprofen and/or antacid to:

Student’s Name: ________________________________________ while a student at Kickemuit Middle School.

Parent/guardian Signature: __________________________________ Date: _________________

Home Telephone: __________________________________________________

Parent/Guardian Cell phone: _________________________________________

Parent/Guardian Work telephone: _____________________________________

*Note: Please be sure the school has current home, cell, work & emergency contact information for this student.

Any changes should be placed in writing, signed and sent into the main office. Thank you

Mrs. Erin Welchman RN

School Nurse

KICKEMUIT MIDDLE SCHOOL

Dear Parent/Guardian: Please assist me in updating your child’s school health record. Please complete this form and return it to school. 1. Student’s Name

2. Physician/Health Center Name

Telephone # Date of last physical examination

3. Does your child have a health problem? Diabetes Asthma Seizures Heart Skin

Menstrual issues Migraines/frequent headaches Stomach Bowel/bladder

Vision glasses/contacts Hearing Emotional/mental health issues

Recent injuries/surgery 4. Does your child take any medication on a daily basis? Reason

Name of medication Amount

Time of day given

Are there any medications your child needs to use on an ‘”as needed basis”?

Name of medication Amount

Reason for medication

5. Does your child have any allergies? Please list them

Type Reaction Treatment

6. Is there anything more about your child’s health that you think is important for me to know?

Please call me if you have any health concerns about your child you would like to discuss, at 245-2010, Ext. 2009. Be sure your emergency contact phone numbers are correct. Thank you, Mrs. Erin Welchman, RN

Parent’s Signature Date: ________

Student Name: Last First Middle Date of Birth Sex

Address: Street Apt # City State Zip Code Home Phone

KICKEMUIT MIDDLE SCHOOL Health Care Provider Name and Address

525 CHILD STREET

WARREN, RI 02885 PHONE:

STATE OF RHODE ISLAND SCHOOL PHYSICAL FORM

This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4)

PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript). IMMUNIZATIONS Please enter dates in MM/DD/YYYY format

Hepatitis B

Diphtheria-Tetanus-Pertussis DTP/DTaP

Check if DT

Check if DT

Check if DT

Check if DT

Check if DT

Pneumococcal Conjugate PCV

Polio Haemophilus Influenzae Type B

Hib

Measles-Mumps-Rubella MMR

Varicella

Student has history of varicella disease Tetanus-Diphtheria-Pertussis

TdaP/Td Check if Td Check if Td Check if Td

Rotavirus

Hepatitis A

Meningococcal

HPV

Immunization Exemption: Medical Religious

Hep B DTaP PCV Polio Hib MMR Varicella Td/Tdap Rotavirus Hep A Mening HPV

PHYSICAL EXAMINATION

Date of PE / / Height Weight BP

Please note any health problem, chronic health condition or disability that may affect behavior or health at school:

ASTHMA: No Yes DIABETES: No Yes OTHER:

Significant Systems Findings:

ALLERGIES: No Yes (Please explain) EPINEPHRINE AUTO-INJECTOR REQUIRED: No Yes

Treatment Plan:

MEDICATION (REQUIRED AT SCHOOL): No Yes (Please list)

Other medication(s) that may affect behavior or health at school:

RESTRICTIONS: Can participate in physical education: Fully With limitation

Can participate in sports: Fully With limitation

LEAD SCREENING (Required for children < 6 years of age only) Student is in compliance with lead screening requirements:

Yes No

SCOLIOSIS SCREENING

Yes No

VISION SCREENING (Children entering Kindergarten) Passed screening Screened and referred for comprehensive exam

Referred for comprehensive exam, but not screened

Screening Date: Comprehensive Exam Date: TUBERCULOSIS (If required by school district) Date of TB test:

HEALTH CARE PROVIDER SIGNATURE: DATE:

PRINT NAME: _________________________________________________________________

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