Kindergarten registration forms - Brentwood Borough School District

BRENTWOOD BOROUGH SCHOOL DISTRICTENROLLMENT RECORD3601 Brownsville RoadPittsburgh, Pennsylvania 15227All information provided on this form will be kept in a confidential file. Access to this file is limited to school personnel.Please supply documented proof of immunization (Physician's Record) and age (original birth certificate). These documentswill be photocopied by the school official.STUDENT INFORMATION:STUDENT NAME:LAST FIRST M.I.HOME ADDRESS:TELEPHONE: SOCIAL SECURITY NO.: - -SEX: DATE OF BIRTH: - -DATE OF ENTRANCE:GRADE ENTERING:Please list previous schools, beginning with last one attended, include pre-school and nursery schools:SCHOOL ADDRESS GRADEDid the child repeat any grades?If yes, what grades?Did the child receive any of the educational services listed below at previous schools?If so, please check the service and indicate the grade or grades.SERVICE GRADE SERVICE GRADESPEECH/LANGUAGE/ESLVISION THERAPYCOUNSELINGPSYCHOLOGICAL TESTINGGIFTED AND TALENTEDTRANSITIONAL CLASSESHEARING THERAPYREMEDIAL READINGREMEDIAL MATHLEARNING SUPPORTEMOTIONAL SUPPORTEXTENDED DAY CLASSES

FAMILY INFORMATION:Father's full name:circle oneCell phone(Mom/Dad):Father's employer:Father's work phone:Mother's full name:Mother's maiden name:Mother's employer:Mother's work phone:E-Mail Address: _________________________________________________________________________MARITAL STATUS:MarriedSingleSeparatedDivorcedDivorced/primary caretaker re-married (father/mother) – circle oneDeceased (father/mother)NAMES OF ALL PERSONS LIVING WITH THE CHILD:LAST NAME FIRST NAME RELATIONSHIPBROTHERS/SISTERS: BIRTHDATE AGE GRADETo the best of my knowledge, the information provided on this form is accurate.Signature Relationship to child Date

BRENTWOOD ELEMENTARY SCHOOLSHealth History and Certification of Immunization StatusStudent’s NameBirth DateGradeSexHome AddressHome PhoneFather’s NameMother’s Name (include maiden name)Person with whom student lives (if other than parents)VACCINES RECEIVEDThe Commonwealth of Pennsylvania requires that students have a certain number of the followingimmunizations before they can be admitted to school. Please enter the date that each dose wasreceived.Vaccine # required 1 2 3 4 5Any combination of DTP,DT, and TD4(last one must beafter 4th birthday)OPV (oral polio) 3MMR (measles, mumps,rubella)2Hepatitis B 3Varicella (or date that yourChild had chickenpox)1The Commonwealth of Pennsylvania also mandates that physical examinations be done inkindergarten (or upon entrance to school), 6th grade and 11th grade. Dental examinations arerequired in grades 1, 3 and 7.I prefer that my child be examined by:my personal physicianthe school physicianI prefer that my child be examined by:my personal dentistthe school dentistSignature of ParentDatePLEASE COMPLETE OTHER SIDEHAS YOUR CHILD HAD ANY OF THE FOLLOWING: (please give details)

Ear problems:Vision/eye problems:Hospitalization:Chronic or recurrent illness or condition:Serious accident or injury:Operations:Emotional Problems:Seizures:Asthma:Allergies:Please list any other health concern which you or your family feel should be known to schoolauthorities:Please list ANY MEDICATIONS that your child takes on a regular basis and note whether it will benecessary for your child to receive it at school.WOULD YOU LIKE A CONFERENCE WITH THE SCHOOL NURSE? Yes No

BRENTWOOD BOROUGH SCHOOL DISTRICTHOME LANGUAGE SURVEY*The Office of Civil Rights (OCR) requires that school districts/charter schools/full dayAVTS identify limited English proficient (LEP) students in order to provide appropriatelanguage instructional programs for them. Pennsylvania has selected the HomeLanguage Survey as the method for the identification.School District: Brentwood Borough School DistrictSchool: Elroy MooreStudent’s Name:Date: ____________Grade: Kindergarten1. What is/was the student’s first language? __________________________2. Does the student speak a language(s) other than English?(Do not include languages learned in school.)YesNoIf yes, specify the language(s): ____________________________________3. What language(s) is/are spoken in your home? ______________________4. Has the student attended any United States school in any 3 years duringhis/her lifetime?YesNoIf yes, complete the following:Name of School State Dates Attended______________________ _____________ ________________________________________ _____________ ________________________________________ _____________ __________________Person completing this form (if other than parent/guardian):Parent/Guardian signature:*The scho ol district/ch arter sch ool/full d ay AVT S h as th e respo nsibility u nder th e federal law toserve students who are limited English proficient and need English instructional services. Given thisresponsibility, th e schoo l district/charter scho ol/full day AVTS h as th e ri ght to ask for th einformation it needs to identify English Language Learners (ELLs). As part of the responsibility tolocate and ide ntify ELLs, the school distri ct/charter school/full day AVTS m ay conduct screeningsor ask for related information about students who are already enrolled in the school as well as fromstudents who enroll in the school district/charter school/full day AVTS in the future.Revised 10/19/05

SPEECH AND LANGUAGE QUESTIONNAIRESS#StudentBirth dateGrade enteringParent(s) with whom student livesSiblings and their agesAddressHome phoneWork phoneMy child is currently receiving speech and language therapy.Agency nameMy child was but is no longer receiving speech and language therapy.Agency nameMy child has never received speech and language therapy.My child says all speech sounds correctly.My child does not say all speech sounds correctly.To the best of your knowledge, please list all of the speech sounds which your child does not saycorrectly.How well do you understand your child’s speech?Not well at all 1 2 3 4 5 Very WellHow well do you think others understand your child’s speech?Not well at all 1 2 3 4 5 Very WellPlease comment on your child’s general communication skills. Include any medical information which may berelevant.THANK YOU FOR YOUR TIME.

RESIDENCY VERIFICATION PACKAGEThank you for your interest in the Brentwood Borough School District. The following is a list ofthe documentation you will need to provide at the time of your registration. This will help tomake your registration as fast and easy as possible. Please allow a minimum of three (3)working days from the date all records have been submitted, for the district to complete theregistration process.If you are a Resident in the Brentwood Borough School District1. A copy of your child’s birth certificate and/or court order listing you as custodial parent orguardian.2. As parent or guardian, you must present documentation in your name demonstrating thatyour residence is within the Brentwood Borough School District. You will have to providetwo (2) of the following:a. A valid Pennsylvania Driver’s License or Pennsylvania Photo ID Card with the addressof your residence.b. Proof of utilities in your name at the address of your residence. These include gas,electric, sewage, or phone.c. A rent or mortgage certificate or bill with the name and address of your residence.d. A valid U.S. Passport with the name and address of your residence.e. A payroll check or government check stub with the name and address of your residence.f. An IRS tax return within the last year with name and address of your residence.If you currently are not a resident of the Brentwood Borough School District1. Proof that as a parent or guardian, you have executed a contract to buy or rent a residence inthe Brentwood Borough School District. This would include a copy of your sales agreementto purchase the residence or a rental agreement.Once your residency is verified, you will be given the enrollment packet to complete. Thisinformation must be completed before your child can be enrolled in the Brentwood BoroughSchool District.If you have any questions, please feel free to contact the building principals at their respectiveschools. We are looking forward to enrolling your child into our school district.

BRENTWOOD BOROUGH SCHOOL DISTRICTRESIDENCY VERIFICATIONParent/Guardian/Foster ParentHome Telephone NumberAddressWork Telephone NumberStudent Name Grade AgeStudent Name Grade AgeStudent Name Grade AgeSection 1 Please read and answer all questions that apply.1. Are you the child’s custodial parent or guardian? Yes NoIf yes – present copy of birth certificate and/or court order and go toquestion #4If no – go to question #22. Are you a foster parent to the child? Yes NoIf yes – complete questions 3 through 5If no – complete Parents’ Declaration and Authorization for Admissionof Non-resident Student, then complete questions 4 and 53. As a foster parent, are you receiving any form of compensation to support Yes Nothis child?4. Are you currently a resident of the Brentwood Borough School District?If yes – proceed to question #5If no – go to Section 2 on the back of this form5. At this time, you must present documentation in your name demonstrating that your residence iswithin the Brentwood Borough School District. The District will accept any two (2) of the followingforms of documentation:a. A valid Pennsylvania Driver’s License or Pennsylvania ID Card with the address indicated above.b. Proof of utilities in your name at the indicated address. These include gas, electric, sewage, water,or telephone.c. A rent or mortgage certificate or bill with the name and address listed above.d. A valid U.S. Passport with the name and address listed above.e. A payroll check or government check stub with the name and address listed above.f. An IRS tax return within the last year at the address listed above.