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MILLBROOK CENTRAL SCHOOL DISTRICT (Millbrook Central School District)

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MILLBROOK CENTRAL SCHOOL DISTRICT
Registration Documentation Affidavit
Name of Student:_______________________________________________________________
(please fill out an affidavit for each student registered)
Name of Parent/Guardian:________________________________________________________
Address:______________________________________________________________________
Town:________________________________________ Zip Code:_____________________
I have submitted documentation in support of my claim to entitlement to a free education for my
child as a resident of the Millbrook Central School District. I have provided this information to
the Millbrook Central School District with the understanding that if I have misrepresented
information contained in the registration packet that such misrepresentation constitutes the filing
of a false report with a governmental agency in violation of the provision of Section 210.45 of
the New York State Penal Law (found below) and I may be held civilly and criminally liable for
such misrepresentation. I have read, understand and swear/affirm to the foregoing under the
penalties of perjury.
Signature of Parent/Guardian:______________________________________________________
Sworn to before me this
_____ day of _______________, 20_____
__________________________________
Notary Public
NEW YORK PENAL LAW § 210.45 - Making a punishable false written statement
A person is guilty of making a punishable false written statement when he knowingly makes a
false statement, which he does not believe to be true, in a written instrument bearing a legally
authorized form notice to the effect that false statements made therein are punishable. Making a
punishable false written statement is a Class A misdemeanor.
Millbrook Central School District
Student Registration Form
2019
(PLEASE PRINT LEGIBLY)
Student Information:
Legal Last Name:
Legal First Name:
Legal Middle Name:
Residence (911) Street Address:
Mailing Address:
Home Phone:
Listed Unlisted
Birthdate: (Month/Day/Year)
Gender:
F M
Birthplace: City State
Student born in the U.S. ? Yes No If No: What is his/her residency status?____________________________
Birth country?____________________________ Date Moved to US?_______________________
Student lives with: Both Parents
Mother only Father only
Mother/Stepfather Father/Stepmother
Guardian:________________________________
Ethnic Information: Hispanic? Yes No
Race (check all that apply) White/Caucasian Black/African American
American Indian/Alaskan native Native Hawaiian/Other Pacific Islander
Asian
Primary Language spoken by child:
Family Information (Parents/Guardians WITH whom the student lives):
(1) Relationship to Student:
______________________________
Last Name:
First Name:
Do you:
Rent
Own
Home Phone:
____________________________________________________________
Work Phone:
____________________________________________________________
Cell Phone:
Email Address:
Serving in Military? Yes No
Occupation:
Employer:
(2) Relationship to Student:
______________________________
Last Name:
First Name:
Do you:
Rent
Own
Home Phone:
____________________________________________________________
Work Phone:
____________________________________________________________
Cell Phone:
Email Address:
Serving in Military? Yes No
Occupation:
Employer:
Family Status: Married Divorced Separated
Single Widowed Other
Is there a custody or parenting plan in effect? Yes No
If yes, plan must be on file with the school for enforcement.
Is there an order of protection/restraining order in effect? No Yes Against Mother Father Other________________
(if yes, legal papers must be on file with the school for enforcement)
_
_____________________
2019
Millbrook Central School District
Student Registration Form
Family Information Parents/Guardians NOT living with student):
Relationship to Student:
___________________________
Last Name:
First Name:
Residence (911) Street Address:
Mailing Address:
Home Phone:
Listed Unlisted
Work Phone:
Cell Phone/Pager:
Email Address:
Serving in Military? Yes No
Occupation:
Employer:
Special Services:
Has student ever qualified for or been enrolled in a Special Ed.
program? Yes No
Has student ever qualified for or had a 504 plan?
Yes No
Has student ever participated in:
Title I/LAP? Yes No OT/PT Yes No
IEP? Yes No Speech Therapy Yes No
Gifted? Yes No Other Yes No (Specify):__________________________
Has student ever been enrolled in a Second Language Program? Yes No
Please list any other schools student has attended:
School Name
Teacher
Address
Phone
Dates Attended
Millbrook Central School District
Student Registration Form
2019
Sibling Information:
Full Name
Gender
Birth date
Grade in School
EMERGENCY CONTACT INFORMATION
In case of emergency and parents are not available, contact:
Name:_______________________________Relationship:____________________ Phone:
Name:_______________________________Relationship:____________________ Phone:
Name:_______________________________Relationship:____________________ Phone:
Name:_______________________________Relationship:____________________ Phone:
________________
________________
________________
________________
In case of accident or s
erious illness, I request the school to contact me. If the school is unable to reach me, I hereby
authorize the school to contact the local rescue squad for support.
Parent/Guardian Signature:_________________________________________Date:__________________
School Information: (office use only)
Elm Drive Elementary (K-2) Alden Place Elementary (3-5 )
Millbrook Middle School (6-8) Millbrook High School (9-12)
School ID:________________ Bus Route:____________ Home:______________
Other:____________
Grade: ___________ Homeroom:____________ Teacher: ____________________________________
Transportation: Bus To Bus From Walker Parent Pick-
Up Student Driving
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 Colón-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 ANGUAGE C ODE
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
T
T
H
H
I
I
S
S
S
S
E
E
C
C
T
T
I
I
O
O
N
N
T
T
O
O
B
B
E
E
C
C
O
O
M
M
P
P
L
L
E
E
T
T
E
E
D
D
B
B
Y
Y
D
D
I
I
S
S
T
T
R
R
I
I
C
C
T
T
I
I
N
N
W
W
H
H
I
I
C
C
H
H
S
S
T
T
U
U
D
D
E
E
N
N
T
T
I
I
S
S
R
R
E
E
G
G
I
I
S
S
T
T
E
E
R
R
E
E
D
D
:
:
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 ENDER:
Male
Female
Month
Day
Year
P A R E N T /PE R S O N I N P A R E N T A L RE 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 ID N U M B E R I N NYS 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 ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:
P
P
.
.
O
O
.
.
B
B
O
O
X
X
A
A
A
A
M
M
I
I
L
L
L
L
B
B
R
R
O
O
O
O
K
K
,
,
N
N
E
E
W
W
Y
Y
O
O
R
R
K
K
1
1
2
2
5
5
4
4
5
5
O
O
F
F
F
F
I
I
C
C
E
E
O
O
F
F
T
T
H
H
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E
S
S
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P
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R
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N
N
T
T
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E
N
N
D
D
E
E
N
N
T
T
ENROLLMENT FORM - RESIDENCY QUESTIONNAIRE
Name of LEA:
N
ame of School:
Name of Student:
Last First Middle
Gender: Male Date of Birth: / / Grade: ID#:
Female Month Day Year (preschool-12) (optional)
Address: Phone:
The answer you give below will help the district determine what services you or your child may be able to
receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are
entitled to immediate enrollment in school even if they don’t have the documents normally needed, such
as proof of residency, school records, immunization records, or birth certificate. Students who are
protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please check one box.)
In a shelter
With another family or other person because of loss of housing or as a result of economic hardship
(sometimes referred to as “doubled-up”)
In a hotel/motel
In a car, park, bus, train, or campsite
Other temporary living situation (Please describe):
In permanent housing
Print name of Parent, Guardian, or Signature of Parent, Guardian, or
Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth)
Date
NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a
Designation Form is completed.
MILLBROOK CENTRAL SCHOOL
Student Race & Ethnicity Identification Form
• 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.
Student Name:
(Last, First, Middle)
Date of Birth:
(Month/Day/Year)
Grade:
ID#
Elm Drive
Alden Place
MMS
MHS
Do you consider yourself as:
________Yes - Hispanic or Latino
________ No, not Hispanic or Latino
A person of Mexican, Puerto Rican, Cuban, Central or South American, or other
Spanish culture of origin, regardless of race.
Race Definitions What is your race? Please check all that apply:
_______American Indian or Alaskan Native: A person having origins in any of the
original peoples of North and South America (including Central America) and who maintains a tribal
affiliation or community attachment. For example: Cherokee, Mohawk, Inuit.
______Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent. This area includes: 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, or African American: 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.
Signature of Parent/Guardian Date
2018/2019
MILLBROOK CENTRAL SCHOOL DISTRICT HEALTH HISTORY
Student name:_______________________________________________ Sex:______ Date of birth:______________
(Last, First, MI)
Parent/Guardian: ______________________________________________Relationship to child:_________________
Parent/Guardian: ______________________________________________Relationship to child:_________________
Siblings:___________________________ Date of Birth:________ ___________________________Date of Birth:_________
___________________________________Date of Birth:________ ___________________________Date of Birth:_________
Check YES or NO to all items. Provide details on right for any items marked YES.
YES NO
ALLERGIES Details / Dates
*List specific allergy and type of reaction
Food allergy
Peanut allergy
Tree nut allergy
Medication allergy
Seasonal or environmental allergies
Allergy to bees, other stinging insects
History of sting allergy in family (specify)
Has child ever been stung ?
Does child have an Epi-Pen ?
Other allergies:
YES NO
Health Conditions Details / Dates
Asthma / Reactive airway
Does child use an inhaler and/or nebulizer?
Pneumonia or lung disorder
Heart murmur
Heart condition / high blood pressure
Bleeding disorder / Anemia
Diabetes Date diagnosed:
Insulin dependent: Yes / No
Diabetes in immediate family?
Seizure disorder
Type: Medication:
Serious concussion or head injury
Recurrent headaches /migraines
Serious accident / injury
Surgery / Hospitalizations:
Fractures : specify
Joint or muscle disease / orthopedic problems
Scoliosis or abnormal spinal curve
Kidney or urinary problems
Bowel or digestive problem
Lactose intolerance
Gluten intolerance (celiac disease)
Skin condition
Lyme disease
Rheumatic fever
MILLBROOK CENTRAL SCHOOL DISTRICT HEALTH HISTORY
Check YES or NO to all items. Provide details on right for any items marked YES.
YES NO
Health Conditions Details / Dates
Mononucleosis (Mono)
Chicken pox (varicella)
Attention Deficit Disorder (ADD or ADHD)
Date diagnosed:
Current medication:
Previous medication:
Autism / Asperger's
Neurological disorder
Behavioral or psychological disorder
Other:
YES NO
Specialists / Services Details / Dates
Speech/Language
Occupational Therapy
Physical Therapy
Neurologist
Psychology services
Allergist
Ear, Nose and Throat Specialist / Audiologist
Ophthalmologist / Optometrist
YES NO
Hearing and Vision Details / Dates
Frequent ear infections / fluid in ear
Hearing loss: Left Right
Due to: Last evaluation:
Hearing aid
Vision problems/ eye defect
Date of last vision exam:
Wears glasses Contacts Both
At all times: Distance:
Reading:
Color deficiency
Other:
List all medications your child takes on a daily or frequent basis:____________________________________________________
___________________________________________________________________________________________________________
*Are there any medications to be taken while school is in session?___________________________________________________
*School medication policy, including physicians order, must be followed.
List any health concerns not previously addressed:________________________________________________________________
__________________________________________________________________________________________
Parent/Guardian Signature________
______________________________________Date:______________
(4/25/08)
Rev. 5/4/2018 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
☐ HbA1c 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.
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
_________________________ _____________
Rev.
5/4/2018 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.
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MILLBROOK CENTRAL SCHOOL DISTRICT (Millbrook Central School District)

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Completed 25 July 2021

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