Madison Public Schools TO ESTABLISH RESIDENCY STUDENT ENROLLMENT

Madison Public Schools10 Campus DrivePO Drawer 71Madison, CT 06443-2562(203) 245-6300 Fax (203) 245-6330TO ESTABLISH RESIDENCY- Copy of a Purchase and Sales Agreement showing purchaser's name, address of property in Madison and closing date. If closing hasoccurred please contact the Madison Public Schools Central Office (203) 245-6300 or email questions directly to:residency@madison.k12.ct.us- Copy of rental lease showing date rental begins and ends, name of parties renting the property and name of owner.- Resident Affidavit - Used in the event the incoming student resides with family member or friend temporarily while awaiting housingin Madison. Affidavit must be completed by the Madison resident and notarized.- Parent/Guardian Affidavit - To be completed by a parent who does not reside in Madison because the child is living with anotherparent/guardian who does live in Madison. A copy of a court-ordered guardianship document is required or a notarized affidavit mustbe completed by the non-custodial parent.- Pupil / Student Affidavit - To be completed by a student over the age of eighteen (18) who resides in Madison and qualifies to attendhigh school. Parents may or may not reside in Madison, the student must reside in Madison.STUDENT ENROLLMENTStudent enrollment forms may be obtained at the Madison Public Schools Central Office, 10 Campus Drive, Madison, CT 06443 ordownloaded from the district website www.madison.k12.ct.usHealth Information:- Physical examinations are mandated by the State of Connecticut for all Pre-K, Kindergarten, 6th and 10th grade students.Kindergarten physicals performed 12 to 15 months prior to entry into Kindergarten are acceptable, provided they are onthe blue State Health Assessment Record form.- All out-of-state students are mandated by the State of Connecticut to have a physical assessment performed before enteringConnecticut schools. If the assessment was done in the previous state within one year of entry into Connecticut schools it can beaccepted on the blue Connecticut State Health Assessment Record form.- Students entering from outside of the United States are required to have a physical exam by a provider licensed to practicein the United States. TB Testing must be included in this exam.- Sports physical examinations are required every 13 months after the initial exam for all students in accordance with ConnecticutInterscholastic Athletic Conference recommendation and school policy. The completed forms must be on file in the school HealthOffice before any student will be allowed to try out, practice or compete in any sport or cheerleading. Student athletes ingrades 6 and 10 must have the blue State Health Assessment Record form completed in addition to the sports physicalexamination form.- Immunizations required for school entrance must be reviewed by the school nurse before the student can be cleared for entry.- if it is necessary for your child to take medication during school hours an authorization form can be obtained from the SchoolHealth Office.- Please inform the nurse of food allergies, diabetes, asthma or any health concern that may impact your child's safety. Appropriatepersonnel and transportation services will be informed of serious health conditions.School Visitation:- Kindergarten through 6th grade may wish to schedule an appointment for school visitation.- Grades 7 - 12 are required to schedule an appointment with the guidance office at the applicable school. The appointment is toschedule appropriate classes for the upcoming school year. Please bring student's last report card from the previous school or acopy of the student's complete academic file. Both the student and parent/guardian are required to attend.- It is the responsibility of the parent/guardian to call the school and initiate the appointments.- Central Office receives all student enrollment forms and will forward to the appropriate resident school for the student's gradelevel.If you have any questions regarding this information or have circumstances that do not meet the above referenced criteria, please contactthe Madison Public Schools Central Office at (203) 245-6300 or email questions directly to : residency@madison.k12.ct.us

MADISON PUBLIC SCHOOLS10 Campus Drive, Madison, CT 06443 | (203) 245-6300Today's DateSTUDENT ENROLLMENT FORMStudent ID #STUDENT INFORMATIONLast Name First Name Middle NamePresent GradeGenderMALEFEMALEDate of BirthHome AddressHome PhonePlace of BirthSocial Security Number (optional)Citizenship CountryETHNICITY1. IS THIS CHILD HISPANIC/ LATINO? YES NO2. What is the child's race?(Please check one or more, even if you answered "yes" to question 1) Note: A parent has the right to refuse to provide this informationAmerican Indian or Alaska NativeBlack or African AmericanAsianNative Hawaiian or Other Pacific IslanderWhiteStudent Lives With:Both Parents Mother Only Father Only Other: (describe)Last School Attended: (include pre-school)Name/AddressLast GradePrevious Home AddressPARENT /GUARDIAN INFORMATION (1) Mother Guardian 1 OtherLast Name First Name Middle InitialAddress:Same as studentResidence Address:Mailing Address:Home Phone Cell Phone Work PhoneEMAIL US Citizen YES NO Responsible for StudentYESNOPARENT /GUARDIAN INFORMATION (2) Father Guardian 2 OtherLast NameFirst NameMiddle InitialADDRESS:Same as studentResidence Address:Mailing Address:Home Phone:Cell Phone:Work Phone:EMAILUS CitizenYESNOResponsible for StudentYESNOREV. 02/2013Page 2 of 5

Madison Public SchoolsMadison, ConnecticutParent / Guardian Permissions FormPlease sign each of the boxed sections below to grant individual permissions for your child.Student's Name:GradeSchoolUNSCHEDULED EARLY DISMISSAL - Emergency or Inclement WeatherIn the event of an unscheduled early dismissal, my child should:Ride his/her assigned bus homeRide his/her scheduled daycare provider as previously filed in the school officeWill be picked up by:Name:Relationship to student:Parent/Guardian Signature:DatePARENTAL PERMISSION OF STUDENT MEDIA COVERAGE / VIDEOTAPING / PHOTOGRAPHSMadison Board of Education Policy #5180.4 provides guidelines for the inclusion of schools or students for publicity purposes. The policyrequires that parents be given the opportunity to withhold permission for interviews, photographs, and videotaping of their child atschool. For media coverage featuring specific students and/or potentially controversial issues, individual parental permission will berequested and obtained.I agree to allow my son/daughter to be interviewed, photographed, or videotaped in conjunction with school related policy.I refuse permission for my son/daughter to be interviewed, photographed, or videotaped in conjunction with school related play.Parent/Guardian) Signature:DateRev. 03/2014

Madison Integrated PreschoolMadison Town Campus Learning Center (TCLC)2014-2015 Typical PeerFees and Program SelectionSTUDENT / PARENT INFORMATIONLast Name: First Name: Middle:Date of Birth: Gender: Male FemaleParent/Guardian:Address:Telephone Numbers:Home Phone: Cell Phone: Work Phone:Emergency Contact (other than parent)Phone NumberRelationship to StudentFEE AND SESSION SELECTIONFull day is available for our current tuition students, ages 3-5, and those who have been screened and determined to be typicallydeveloping. There are a limited number of spaces available on a first-come, first-serve basis.Select the 3 day, 5 day or Other program. Fee is $20 per session for 1/2 day, $30 per session for full day (minimum 3 days a week for fullday)3 day - 1/2 day program $60 per week5 day - 1/2 day program $100 per week3 day - full day program $90 per week5 day - full day program $150 per weekAM sessionPM SessionPlease select days attending:Monday Tuesday Wednesday Thursday FridayA screening for typical peers is required. Please bring this completed form and your deposit check of $100 (which will be deductedfrom your first invoice) to TCLC to register and schedule an appointment for screening.There is an AM and a PM session Please indicate your preference. We will make every effort to honor your preference. If we are fullyenrolled in AM or PM and cannot honor your preference, we will call you to check on your interest in the available session. If the AM/PMsessions are filled, a waiting list will be maintained.PaymentMadison Public Schools will send you a monthly invoice. The invoice will indicate the number of school days, due date, and paymentamounts.Please make all checks payable to Madison Public Schools (please do not include cash).