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Welcome to the Great Neck School District (516) (Rialto Unified School District)

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Great Neck Public Schools
Phipps Administration Building
Office of Registration
345 Lakeville Road
Great Neck, NY 1102
(516) 441-4080
Welcome to the Great Neck School District
You must reside in the District in order to register your child for school. Registration is a three step process.
Step one move in. The second step is to complete and submit the Online Registration Application. After the
application is submitted you will receive an email letting you know you can come in to the Office of
Registration, Phipps Administration Building, any school day between 8:30 and 3:30, where you will complete
the third step. Call for hours on non-school days.
For the Online Registration link and direction go to: https://www.greatneck.k12.ny.us Administration>Registration
Before you begin the online registration, please gather the following documents and scan
them to your computer so you can upload them during the registration process.
There are a few documents which the Registration Office will need to see the original. (Proof of age:
Original Birth Certificate, Photo ID of Parents/Guardians, Certificate of Residency) All other documents only
need to be scanned through the portal.
The following documents are required for registration and can be uploaded into the Online
Registration System. In the event the family is not able to present the required documentation, an appointment may
be requested with the supervisor to determine what other documents will be acceptable to register the student in school.
Acceptable Proof of Residence: All of these will be uploaded while filling out the Online Application.
If homeowner, please provide one (1) of the following: Deed, Current Town or North Hempstead Tax
Bill (If you need a copy call (516) 869-7800), Closing statement, Proprietary lease (for Co-op).
If renting with or without lease, please provide the following: Either a Signed Current lease with
dates OR (2) Notarized Residency Affidavits for Tenant and Owner Affidavits (provided by the district).
In addition to the Owner Affidavits, one (1) of the following in the property owner’s name: Deed,
Current Town or North Hempstead Tax Bill (If you need a copy call (516) 869-7800), Proprietary lease
(for Co-op)
AND
3 Pieces of Current Official Mail (i.e. bank statements, credit card statements, insurance bills, cell
phone bills, and utility bills, etc.) dated current or past month only).
Additional Documentation:
Student Records The following student records are also required:
▪ Proof of Age (Original Birth Certificate). If not in English an Official Notarized Translation is
required. (All students)
▪ Up-to-Date Immunization Record signed and stamped by a doctor. If entering Public School
only)
▪ Physical (by a New York State Doctor within 30 days of starting school, the physical must have
been performed within the last 12 months. If entering Public School only)
▪ School Records (i.e. report card, official transcript, course schedule. If entering Public School
only)
▪ If a student is receiving special education services, a copy of the IEP is required.
Proof of Guardianship/Parental Relationship. (Not required if parent is listed on birth certificate)
If parents divorced, Family Court or Divorce Agreement naming registering parent as custodial
parent or having residential custody, or signed and notarized affidavits obtained from our office.
Note: In the event of Divorce or Separation, both parents have equal access to their
children and student records, unless legal documentation is submitted at Registration
limiting this.
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
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
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B
B
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E
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C
O
O
M
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D
D
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Y
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D
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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:
Vaccines
Prekindergarten
(Day Care,
Head Start,
Nursery
or Pre-k)
Kindergarten and Grades
1, 2, 3, 4 and 5
Grades
6, 7, 8, 9, 10
and 11
Grade
12
Diphtheria and Tetanus
toxoid-containing vaccine
and Pertussis vaccine
(DTaP/DTP/Tdap/Td)
2
4 doses
5 doses
or 4 doses
if the 4th dose was received
at 4 years or older or
3 doses
if 7 years or older and the series
was started at 1 year or older
3 doses
Tetanus and Diphtheria
toxoid-containing vaccine
and Pertussis vaccine
booster (Tdap)
3
Not applicable 1 dose
Polio vaccine (IPV/OPV)
4
3 doses
4 doses
or 3 doses
if the 3rd dose was received
at 4 years or older
4 doses
or 3 doses if
the 3rd dose
was received
at 4 years or
older
3 doses
Measles, Mumps and
Rubella vaccine (MMR)
5
1 dose 2 doses
Hepatitis B vaccine
6
3 doses 3 doses 3 doses or 2 doses
of adult hepatitis B vaccine
(Recombivax) for children who
received the doses at least 4
months apart between the ages
of 11 through 15 years
Varicella (Chickenpox)
vaccine
7
1 dose 2 doses 1 dose
Meningococcal conjugate
vaccine (MenACWY)
8
Not applicable
Grades
7, 8, 9 and 10:
1 dose
2 doses
or 1 dose
if the dose
was received
at 16 years or
older
Haemophilus influenzae
type b conjugate vaccine
(Hib)
9
1 to 4 doses Not applicable
Pneumococcal Conjugate
vaccine (PCV)
10
1 to 4 doses Not applicable
2019-20 School Year
New York State Immunization Requirements
for School Entrance/Attendance
1
NOTES:
Children in a prekindergarten setting should be age-appropriately immunized. The number of doses depends on the schedule
recommended by the Advisory Committee on Immunization Practices (ACIP). For grades pre-k through 11, intervals between doses of
vaccine should be in accordance with the ACIP-recommended immunization schedule for persons 0 through 18 years of age. Doses
received before the minimum age or intervals are not valid and do not count toward the number of doses listed below. Intervals between
doses of vaccine DO NOT need to be reviewed for grade 12 except for interval between measles vaccine doses. See footnotes for
specific information for each vaccine. Children who are enrolling in grade-less classes should meet the immunization requirements of the
grades for which they are age equivalent.
Dose requirements MUST be read with the footnotes of this schedule.
Departmen
t
of Health
2370
1. Demonstrated serologic evidence of measles, mumps, rubella, hepatitis B, varicella
or polio (for all three serotypes) antibodies is acceptable proof of immunity
to these diseases. Diagnosis by a physician, physician assistant or nurse
practitioner that a child has had varicella disease is acceptable proof of
immunity to varicella.
2. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine.
(Minimum age: 6 weeks)
a. Children starting the series on time should receive a 5-dose series of
DTaP vaccine at 2 months, 4 months, 6 months and at 15 through 18
months and at 4 years or older. The fourth dose may be received as early
as age 12 months, provided at least 6 months have elapsed since the
third dose. However, the fourth dose of DTaP need not be repeated if it
was administered at least 4 months after the third dose of DTaP. The final
dose in the series must be received on or after the fourth birthday.
b. If the fourth dose of DTaP was administered at 4 years or older, the fifth
(booster) dose of DTaP vaccine is not required.
c. For children born before 1/1/2005, only immunity to diphtheria is
required and doses of DT and Td can meet this requirement.
d. Children 7 years and older who are not fully immunized with the childhood
DTaP vaccine series should receive Tdap vaccine as the first dose in the
catch-up series; if additional doses are needed, use Td vaccine. If the first
dose was received before their first birthday, then 4 doses are required,
as long as the final dose was received at 4 years or older. If the first dose
was received on or after the first birthday, then 3 doses are required, as
long as the final dose was received at 4 years or older. A Tdap vaccine (or
incorrectly administered DTaP vaccine) received at 7 years or older will
meet the 6th grade Tdap requirement.
3. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine.
(Minimum age: 7 years)
a. Students 11 years or older entering grades 6 through 12 are required to
have one dose of Tdap. A dose received at 7 years or older will meet
this requirement.
b. Students who are 10 years old in grade 6 and who have not yet received
a Tdap vaccine are in compliance until they turn 11 years old.
4. Inactivated polio vaccine (IPV) or oral polio vaccine (OPV). (Minimum age: 6
weeks)
a. Children starting the series on time should receive a series of IPV at 2
months, 4 months and at 6 through 18 months, and at 4 years or older.
The final dose in the series must be received on or after the fourth
birthday and at least 6 months after the previous dose.
b. For students who received their fourth dose before age 4 and prior to
August 7, 2010, 4 doses separated by at least 4 weeks is sucient.
c. If the third dose of polio vaccine was received at 4 years or older and at
least 6 months after the previous dose, the fourth dose of polio vaccine
is not required.
d. Intervals between the doses of polio vaccine do not need to be
reviewed for grade 12 in the 2019-20 school year.
e. If both OPV and IPV were administered as part of a series, the total
number of doses and intervals between doses is the same as that
recommended for the U.S. IPV schedule. If only OPV was administered,
and all doses were given before age 4 years, 1 dose of IPV should be
given at 4 years or older and at least 6 months after the last OPV dose.
5. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months)
a. The first dose of MMR vaccine must have been received on or after the
first birthday. The second dose must have been received at least 28
days (4 weeks) after the first dose to be considered valid.
b. Measles: One dose is required for prekindergarten. Two doses are
required for grades kindergarten through 12.
c. Mumps: One dose is required for prekindergarten and grade 12.
Two doses are required for grades kindergarten through 11.
New York State Department of Health/Bureau of Immunization
health.ny.gov/immunization
2/19
d. Rubella: At least one dose is required for all grades (prekindergarten
through 12).
6. Hepatitis B vaccine
a. Dose 1 may be given at birth or anytime thereafter. Dose 2 must be
given at least 4 weeks (28 days) after dose 1. Dose 3 must be at least 8
weeks after dose 2 AND at least 16 weeks after dose 1 AND no earlier
than age 24 weeks.
b. Two doses of adult hepatitis B vaccine (Recombivax) received at least 4
months apart at age 11 through 15 years will meet the requirement.
7. Varicella (chickenpox) vaccine. (Minimum age: 12 months)
a. The first dose of varicella vaccine must have been received on or after
the first birthday. The second dose must have been received at least 28
days (4 weeks) after the first dose to be considered valid.
b. For children younger than 13 years, the recommended minimum interval
between doses is 3 months (if the second dose was administered
at least 4 weeks after the first dose, it can be accepted as valid); for
persons 13 years and older, the minimum interval between doses is 4
weeks.
8. Meningococcal conjugate ACWY vaccine. (Minimum age: 6 weeks)
a. One dose of meningococcal conjugate vaccine (Menactra or Menveo) is
required for students entering grades 7, 8, 9 and 10.
b. For students in grade 12, if the first dose of meningococcal conjugate
vaccine was received at 16 years or older, the second (booster) dose is
not required.
c. The second dose must have been received at 16 years or older. The
minimum interval between doses is 8 weeks.
9. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6
weeks)
a. Children starting the series on time should receive Hib vaccine at 2
months, 4 months, 6 months and at 12 through 15 months. Children
older than 15 months must get caught up according to the ACIP catch-up
schedule. The final dose must be received on or after 12 months.
b. If 2 doses of vaccine were received before age 12 months, only 3 doses
are required with dose 3 at 12 through 15 months and at least 8 weeks
after dose 2.
c. If dose 1 was received at age 12 through 14 months, only 2 doses are
required with dose 2 at least 8 weeks after dose 1.
d. If dose 1 was received at 15 months or older, only 1 dose is required.
e. Hib vaccine is not required for children 5 years or older.
10. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks)
a. Children starting the series on time should receive PCV vaccine at 2
months, 4 months, 6 months and at 12 through 15 months. Children older
than 15 months must get caught up according to the ACIP catch-up
schedule. The final dose must be received on or after 12 months.
b. Unvaccinated children ages 7 through 11 months of age are required to
receive 2 doses, at least 4 weeks apart, followed by a third dose at 12
through 15 months.
c. Unvaccinated children ages 12 through 23 months are required to
receive 2 doses of vaccine at least 8 weeks apart.
d. If one dose of vaccine was received at 24 months or older, no further
doses are required.
e. For further information, refer to the PCV chart
available in the School Survey Instruction Booklet at:
www.health.ny.gov/prevention/immunization/schools
For further information, contact:
New York State Department of Health
Bureau of Immunization
Room 649, Corning Tower ESP
Albany, NY 12237
(518) 473-4437
New York City Department of Health and Mental Hygiene
Program Support Unit, Bureau of Immunization,
42-09 28th Street, 5th floor
Long Island City, NY 11101
(347) 396-2433
200ImmRecord.docx 5/17
GREAT NECK PUBLIC SCHOOLS
Health Services
Immunization Record
NAME__________________________________________________________DOB_____________SCHOOL____________________
ADDRESS_______________________________________PHONE___________________GRADE_____TEACHER_______________
Under section 2164 of the New York State Public Health Law, all children attending school,… or any preschool program must be immunized against Diphtheria, Pertussis, Tetanus, Polio, Measles,
Mumps, Rubella, Hepatitis B, Varicella, Meningococcal, Haemophilus Influenza b & Prevnar. Children who attend a preschool…must also show evidence of lead screening.
Please have your Health Care Provider fill in Month, Day & Year of ALL Immunizations. ALL DATES ARE REQUIRED.
Your child may not attend school without this information.
**PLEASE CHECK WITH YOUR DOCTOR FOR THE REQUIRED DOSES FOR YOUR CHILD ACCORDING TO ACIP GUIDELINES**
DTaP → 3-5 Doses Required {Must have 1 Dose given AFTER age 4, prior to Kindergarten}
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____ 5. ____/____/____ 6. ____/____/____
Tdap→ 1 Dose Required {Mandatory Grades 6
th
-12
th
} AND ALSO{Depending on Age & Grade}
1. ____/____/____
IPV → 3-5 Doses Required {Must have 1 Dose given AFTER age 4, prior to Kindergarten}
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____ 5. ____/____/____ 6. ____/____/____
HBV (HEPATITIS B)→ 3 Doses Required
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ Additional Doses: ____/____/____ ____/____/____ ____/____/____
MMR→ 2 Doses Required {1
st
Dose Must be given on or After First Birthday. 2
nd
Dose Required for Kindergarten.}
MMR: 1. ____/____/____ 2. ____/____/____
Or MEASLES: MUMPS RUBELLA
1.____/____/____ 2. ____/____/____ 1. ____/____/____ 2.____/____/____ 1. ____/____/____ 2.____/____/____
VARICELLA VACCINE (CHICKEN POX)→ 2 Doses Required {1
st
Dose Must be given on or After First Birthday.
2
nd
Dose Required for Kind., 1
st
, 2
nd
& 3
rd
Grade AND 6
th
, 7
th
, 8
th
, & 9
th
Grade}
1. ____/____/____ 2. ____/____/____ Or proof of Disease from Health Care Provider→ DATE: 1. ____/____/____
MenACWY / Menactra / MCV4 / Menveo VACCINE→ 1-2 Doses Required {1
st
Dose Required for 7
th
Grade.
2
nd
Dose Required on or After Age 16, &/Or Entering 12
th
Grade.}
1. ____/____/____ 2. ____/____/____
For children entering Preschool program
Hib (HAEMOPHILUS INFLUENZA b)→ 1-4 Doses Required {Depending on Age & Grade}
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____
PREVNAR (PCV) → 1-4 Doses Required {Depending on Age & Grade}
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____
LEAD SCREENING →Required for Preschool → ____/____/____ → ______________
Optional Vaccines
HEPATITIS A Vaccine (HAV)→ 1. ____/____/____ 2. ____/____/____
HUMAN PAPILLOMAVIRUS (HPV)→ 1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____
PPV (Pneumococcal Polysaccharide Vaccine) → 1. ____/____/____ 2. ____/____/____
ROTATEQ→ 1. ____/____/____ 2. ____/____/____ 3. ____/____/____
OTHER VACCINES: ________________________________→ 1. ____/____/____ 2. ____/____/____ 3. ____/____/____
PPD/TB TEST→ ____/____/____ Read ____/____/____ → ________ mm → Result: N___ P___
**Children who have not been immunized may be admitted with 1 Dose of each required vaccine series & has WRITTEN age appropriate appointments
to complete the series according to the ACIP guidelines.**
PHYSICIAN’S SIGNATURE, STAMP, ADDRESS, PHONE NUMBER
____________________________________________________________
DATE: ____/____/____ ____________________________________________________________
___________________________________________________________________
Rev. 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
☐ bA1c 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.
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.
Rev. 01/2017
CERTIFICATION OF RESIDENCY
This is to certify that I, _________________________________________________________________________
1. I understand that this statement is being made UNDER THE PENALTIES OF PERJURY, so that
__________________________________ may be admitted to the schools of the Great Neck Public Schools.
(Name of Child/Children)
2. I am currently residing at ________________________________________________________________
(Address)
________________________________________________________________
as my legal residence. I further certify that I do not maintain another residence outside the boundaries of
the Great Neck School District. I further certify I will be living with my children while they are attending Great Neck
School.
I understand that if I or the above mention child(ren) is (are) found not to be a legitimate residents of the Great
Neck Union Free School District, that I WILL BE LEGALLY RESPONSIBLE FOR AND WILL PAY THE SCHOOL
DISTRICT’S ANNUAL TUITION RATE PER CHILD, RETROACTIVE TO THE FIRST DAY OF ADMISSION, ALONG WITH
ANY COSTS ASSOCIATED WITH ENROLLING YOUR CHILD” and MY CHILD/CHILDREN WILL BE DISENROLLED. I also
realize that theft of governmental services is a crime punishable under the State Penal Law and that a false
statement made in connection with this application will make me liable to criminal prosecution. I have been
informed that the school district will make unannounced home visits for purposes of residency verification.
I further understand that if I move out of the home listed above, I will immediately notify the school district.
I have been informed that the school district may make unannounced home visits for the purpose of residence
verification. I have read and understood the above. [ ] YES
_____________________________________ _________________________
Signature of Parent/Person in Parental Relation Date
Sworn to before me
This _____ day of ____________, 20_____
________________________________
NOTARY PUBLIC
I have read and understood the above and am certifying the resident understands the statement they are signing.
Please attach copy of ID.
_______________________________________ ______________ __________________
Signature of Translator Relationship Phone
Sworn to before me
This _____ day of ____________, 20_____
________________________________
NOTARY PUBLIC
GREAT NECK PUBLIC SCHOOLS
HEALTH SERVICES
DENTAL HEALTH REPORT
(ELEMENTARY SCHOOLS ONLY)
Student’s Name: _________________________ Date: _________
School: ________________________________ Grade: _________
This is to certify that the student named above:
Is under my care for dental treatment: ___________
Has completed dental treatment: ___________
Name of Dentist: ________________________________
Signature of Dentist: ________________________________
Address: ________________________________
________________________________
This report should be returned to the school.
GREAT NECK PUBLIC SCHOOLS
Registration Office
345 Lakeville Road
Great Neck, NY 11021
(516) 441-4080
residency@greatneck.k12.ny.us
Name: ________________________________ Date: ________________
Public School Registration Checklist
_____ Deed, Closing Statement, or Current School/Village Tax Bill
Or
_____ Proprietary Lease (Co-op)
Or
_____ Lease, Rental Agreement, or Notarized Affidavits
_____ Current Mail 3 Pieces of Official Mail dated within the last month
_____ Certification of Residency (notarized) This form cannot be uploaded bring in while
completing registration
_____ Parent/Guardian Photo ID
_____ Custody Agreement or Notarized Affidavits if applicable
_____ Original Birth Certificate (Original and an official, notarized translation to English, if
necessary)
_____ Immunization Record (stamped by a physician)
_____ Physical (by a New York State Doctor within 30 days of starting school, the physical
must have been performed within the last 12 months.)
_____ Dental Form – Elementary Only
_____ Home Language Questionnaire (Download from Website)
_____ Completed Online Registration
_____ Complete the Registration at the Phipps Registration Office
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Welcome to the Great Neck School District (516) (Rialto Unified School District)

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Completed 11 March 2022

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