Union City Board Of Education ALL DOCUMENTS  PRESENTED  MUST  BE  ORIGINAL©  

Students must be present with parent or legal guardian to register

Pre-school children must be 3, 4 and 5 years of age on or before September 1

         

             

 

         

"Proof  of  Residence"            Picture  ID  from  Parent  or  Legal  Guardian  -­‐  select  ONE  from  list  below:  

 

__  Current  Driver's  License  __  Current  NJ  State  ID  Card  __  Valid  Passport    

   

     TWO  (2)  Proofs  of  Residency  from  Parent  or  Legal  Guardian  with        their  name  &  address  on  document:  

 

__  Employment  or  un-­‐  employment  document  or  Health  Benefits  Card  or  Welfare  documents.  

 

__  Voter  registration  card        

__  Utility:  PSE&G,  Water  or  Cable    

__  Property  Owner:    

         Property  tax  bills,  deed,  contract        of  sale,  mortgage,  and  other  evidence  of  property  ownership.      

 

__  Property  Owner  and  Tenant:              A  Lease  of  agreement  with  rent  receipt,  including  deposit  slip  demonstrating  the  property  address  and  tenant  name.  

 

__      Military  status  including  assignment  documents.    

   

Note:      

     If  the  child’s  last  name  differs  from        the  last  name  of  parent  (s),  proof  of  parentage  is  required.    Parent’s  name  change  must  be  documented  (i.e.  marriage  or  divorce  certificate)  

   

 

"Student  Certificates"    

__  Birth  Certificate  ,  Passport    or            Baptismal  Certificate.        

__  Immunization  Records  showing  all  immunizations  are  current.  

 

       TB  SKIN  TEST  (MANTOUX  method  of  PPD  TEST).  Students  cannot  register  until  after  the  TB,  skin  test  has  been  read  and  the  doctor/clinic  has  provided  you  with  written  results.          If  the  TB  test  is  positive,  student  needs  to  provide  proof  of  normal  chest  X-­‐ray  and/or  proof  of  INH  medication  treatment  including  dosage,  date  started  and  date  completed.  

 

__    Medical    “State  of  New  Jersey  Physician  Form  for  Union  City”    

 

__  Report  Card  and  prior  school  records.  Transfer  Card/Withdrawal  Form  from  the  previous  school.      Both  the  transcript  and  withdrawal  form  help  our  counselors  place  your  student  in  the  most  appropriate  classes  for  academic  success.  

__  Special  Accommodations                                                If  the  student  currently  has  an            I.E.P.,  please    bring  documentation  outlining  services    required.      

 

Recommended  to  be        toilet  trained.  

~~~~~~  

_ Legal  Guardianship          Original  Custody  court  document  must  be  signed              and  sealed  by  a  Judge.  

Note:  “Guardian”  means  a  person  to  whom  a  court  of  competent  jurisdiction  has  awarded  guardianship  or  custody  of  a  child,  provided  that  a  residential  custody  order  shall  entitle  a  child  to  attend  school  in  the  residential  custodian’s  school  district  subject  to  a  rebuttable  presumption  that  the  child  is  actually  living  with  such  custodian;  it  also  means  the  Department  of  Children  and  Family’s  for  purposes  of  N.J.S.A.  18A:  38-­‐1(e)  

Union City Board of Education "INTERNET" Public School Student Registration Information Form

Student information:

It is very important that you take the time to write clearly and legibly in ink. tlPre-k through 5

(Last):__________ (First)_________ (Middle I.) __ Address: _____________ City: .,--:::--------State: __ _

Telephone: and Cell:----==------:--------DateofBirth: __ / __ 1__ Sex: M F Age: __ Birthplace: Country: State: _____ City: _____ _

Previous school information:

Has your child ever attended school iu Union City? __ Yes __ No (If Yes) Please fill out below. Name of School: Grade Attended: ___ Year: ___ _

Previous school name: Name:------------=----- Grade: Attending: __ (Finished) __ _ Address: __________ City:----==---- State: Zip Code: ___ _ Phone: __________ ext.:____ Fax: __________ _

Name of person enrolling student:----=-------- Relationship to student: _____ _ Native Language of person enrolling student: _______ _ How long have you lived at this address? (Month/s_ Day/s_ Year/s__)

Parent information: Mother:

Name: (Last): (First): _______ (Maiden):-------Date of birth: __ /_/_ Place of birth: If deceased state year: __ _ Address: City: State: ---Telephone: __________ and Cell: _________ _

Father:

Name: (Last):-----,--.,...---=-----:-:-:--::--- (First): ----:c;:-;----:--,-----Date of birth: __ /_/_ Place of birth:_______ If deceased state year: __ _ Address: --------------,:-:::-City: ________ State: ___ _ Telephone: and Cell: ___________ _

Name of Sibling: ____________ School Attending: _________ Age: __ Name of Sibling: School Attending: Age: __

Who has legal custody of the student/s: _Mother _Father_ Guardian

If you are the legal Guardian of the student, you have to provide details subsequently requested. Submit all original court credentials from a United States Court with the original court seal and a signature of a Judge.

Legal Guardian in(omwtion:

Name: (Last):-----------:::: (First): _______ _ Address: City: _________ State:

(Middle Initial) __

Telephone: and Cell: ___________ _

*Does the student need any Accommodations? __ NO_ YES (If YES) must provide documentation

Signature of Parent/Guardian:-------------- Date: ______ _

All students age 5 to teen must be present with a parent or /ego/ guardian to register!

·Union City Board of Education Office of Technology

3912 Bergen T=pike Union City; NJ 07087

(201) 348-5770

Student Data Collection

Please fill out this c:fata collective survey. Your cooperation is very much appreciated. (This survey is required/mandated by the New Jersey State department of Education and must be completed by all Union CHy students. This survey my affect future school funding.) · ·

Student's Last Name:-------------------------

Student's First Name:-:----------------------.,..---

Student's Middle Name:-----------------------

City and State of Birth:----------------------

City and Country of Birth:-----------------------

Ethnicity: (please circle) Hispanic/Latina: Yes or No

(Please answer YIES if student is of Cuban, Mexican, Puerto Rican, South or Central American,

or-other Spanish Culture/origin, regardless of race. /Answer NO if not Hispanic or Latino.)-

Race: Please check all that applies.

American Indian or Alaskan Native ------'Asian ___ Black/ African American ___ .Native Hawaiian or Pacific Islander ___ White/Caucasian

Health Information: Date of last Medical Exam: (Date, Month, Year) __ / ! __ Date of last Lead Test: (Date, Month, Year) __ / /_-:-Date of Polio Immunization: (Date, Month, Year) __ / / __

Do you have Health Insurance: Yes or No

If YES, name of Health Insurance Provider:------------------

Union City Public- Schools Office of Bilingual/ ESL Education

HOME LANGUAGE SURVEY '

Please ~wer the following questions:

Student's Name: US. Date of Entry: ____ _

Address: ------------------:-----Telephone: ------

Birth Date: -------- Place of Birth:

Please use only ONE LANGUAGE for each answer.

1. What language ilid your child first leain to speak? ---------,--------------

2. What language do you use most often when speaking to-your child at home? ---------

3. What language does your child use most often when speakil{g to you at home?--------

4. What language does your child use most often when speakin_g to brother( sister? --------

5. What language does your child use most often when speaking to other relatives? --------

6. What language does your child use most often when speaking to friends at home?

ParentJGuardian Signature Date

*****************7********************************************************* Dear Parent or Guardian: As required by State and Federal Law (State Bilingual Education Act of 1975, Federal Lau vs. Nichols Supreme Court ruling of 1974), all parents must be surveyed as to the home language of their public school children.

I We request the above information in order to provide a good instructional program for your child. The completion of this survey is manda1Dry, Thank you for your cooperation.

For office use only: LAU: ___ _ ETH: ----

'k/-;r /s~-::--~r ;

Superintendent of Schools

Grade: ___ _

\

\ "'-

Union City Board Of Education

Central Registration Office

PERMISSION FOR MEDICAL SCREENING

Students Name:------------ _________ Date of Birth: __ ! __ ! __ _

(last) (First) (Month) (Day) (Year)

The following services will be given to all new entrants and only in those grades recommended by the State Department of Education.

Record of Child's Health History

Immunization Evaluation and Completion

Heights and Weights

Blood Pressure (Athletes)

Tuberculin Testing

Vision Screening

Hearing Screening

Scoliosis Screening

Physical Examinations for boys and girls will be done throughout the school year. Boys and girls will be examined separately. In the absence of a parent, a nurse and the teacher, will be present when a student is examined by the School Doctor. Parents are encouraged to attend, if possible.

If you wish to obtain the results of the physical screening, please contact the school nurse. In the event that further examination and/or treatment are necessary, the nurse will be available to inform you.

Please indicate with a check mark:

____ I grant permission for the Union City Board of Education, Medical Department to screen my child.

Signature of Parent/Guardian Date

___ I do not grant permission for the Union City Board of Education, Medical Department to screen my child. I will be responsible to obtain these services by my private Doctor and provide the school nurse with the results.

Signature of Parent/Guardian Date

Our sincerely appreciation for your cooperation in helping us provide the best services for your child.

SUPERINTENDENT OF SCHOOLS

FOR OFFICE USE ONLY

SCHOOL _________________ _ HOME ROOM _____ __

Rev.04/06

------------------------------------------------SCHOOLDISTIUCT

Our school district is participating in a system where the federal government's Medicaid will pay state and local school districts for a portion of the costs of health-related special education services provided to Medicaid eligible children. Your child will continue to receive services at no cost to you under this

new system. This initiative simply helps us maximize federal funds in support of local education. The

information you voluntarily provide by completing this consent form will only be used for the purposes identified.

Please fill in the information below, sign the form, and return it to the address iodicated.

CONSENT FOR RELEASE OF INFORMATION TO ACCESS :MEDICAID -REiMBURsEMENT FOR HEALTH RELATED SUPPORT SERVICES

Child'sName: ----~~~------------------~~--~~----------------------------(First) (Mid. Initial) (Last)

Child's Social Security#: ________ / ______ / ___________ _ (If Known)

Child's Medicaid Number: I (If Known)

Child's Date of Birth: _____ ! ______ ! ________ __ (Month) (Date) (Year)

As parent/guardian of the child named above, I give permission to disclose information from my child's educational records to local, state, and federal agency representatives for the sole purpose of claiming Medicaid reimbursement for health related support services in my child's Individualized Education Program (IEP).

Signature: -----------------------------------------Date: (Parent or person in parental relationship) (Month/Day/Year)

Please_ return this form to:

Union City Board of Education Medical Department

3912 Bergen Turnpike Union City, NJ 07087 Tel# 201-271-2289 ext. 1052/1053

Fax# (201) 348-5118

W'"wo,,

;~~~~;~ "ADMINISTRATION OF MEDICATION IN SCHOOL"

School Year: ____ _

Dear Parent or Guardian:

We discourage the administration of medication in the school setting and request that, whenever possible, medications be scheduled during non-school hours. (It is recommentletl the first dose of medication be administered at home.) If your physician has decided it is necessary for your child to receive medication during the school day, it is required that your physician complete the attached document "Instructions/ Physician Order" and the parent bring the orders and medication to the school nurse together. Only the school nurse has the authority to receive medications, do not drop off any medications to any other office.

The medication must in the original bottle with the current prescription label on the container.

The doctor must fill out the attach form completely prior to the school nurse dispensing medication during school hours.

Querido Padre o Guardian:

Aunque noes recomendable administrar medicinas en las escuelas, entendemos que hay excepciones donde es necesario administrar medicinas durante las horas escolares. La enfermera seguini estrictamente las indicaciones de su medico y bajo ninguna circumstancia proveera el servicio a su hijo/a sin una orden actual del doctor. Adjunto a esta carta encontrani un formulario de Instrucciones/Orden de1 Medico que debe completarse y entregarlo en la enfermerfa de Ia escuela.

El medico debe llenar el formulario completamente antes que Ia enfermera de Ia escuela distribuye medicina durante horas escolares.

Le recomendamos que la primera dosis sea administrtula en su cas a.

Name of Student- Nombre del Estudiante

Name of School -Hombre de Ia Escue fa

Gracie-Grado

Name of School Nurse Nombre de Ia Enfermera

Date of birth- Fecha de Nacimiento

School Principal- Director de Ia escuela

Homeroom Aula

Phone number and extension of nurse Numero de Te/efono y extension de enfermeria

I give consent to the school nurse to administer the prescribed medication to my child during school. I also give consent to release this information to appropriate school personnel.

Doy mi consentimiento de que la enfermera de la escuela puede administrar ami hijo!a sus medicamentos7

mientras que este en sesi6n escolar. Toda informaciOn se darii al personal apropiado escolar.

Signature of Parent/Guardian Firma del Padre/Guardian

Date

Print name Parent/Guardian Nombre del Padre/Guardia en letra de molde

Union City Board of Education Medical Department

3912 Bergen Turnpike Union City, NJ 07087 Tel# 201-271-2289 ext. 1052/1053

Fax# {201) 348-5118

Authorization for the School Nurse to Administer Medication

''TO BE COMPLETED BY PHYSICIAN"

INSTRUCTIONS TO ADMINISTER MEDICATION DURING SCHOOL HOURS ONE FORM FOR EACH MEDICATION

Physician's statement:

In order to protect the health of-----,---,----------,-,-,--' it is necessary for the (Student) (DOB)

student have the following medication during school:

DIAGNOSIS: ---------------------------------------------

Name of Medication: _________________________ _

Controlled Substance: YES I NO

Dosage; _____________ _

Route of Administration: __________________ _

Time for Administration~: _________________________ _

Additional Information: _________________________ _

Name of Physician/ Please Print Physician's Signature/Stamp

Address: ____________________ _

Physician Telephone Number: ____________ Date: ____ _

-Page 2 of2-

UNION CITY PUBLIC SCHOOLS PHYSICIAN FORM

TO BE COMPLETED BY THE FAMILY PHYSICIAN AND RETURNED TO SCHOOL PRIOR TO OR ON THE FIRST DAY OF SCHOOL.

0-lndicates Normal

OX- Indicates Abnormal

Child's Name -------'----------------Date of Birth __________ Sex ______ _

Address ______________________ Telephone No.

Height ____________ Weight ________ Blood Pressure _________________ _

General Appearance ---~-~------------Skin __________ .Speech

Teeth _________ Thyroid ___________ Abdomen ___________ Urine _______ _

Nose _________ Thorax Genitalia _________ Rectal _______ _

Throat _________ ,Breast ___________ Hernia ------~----'Nutrition

Tonsils _________ ,Lungs ___________ Extremities

Glands ________ ,Heart ___________ Feet __________ _

Cervical ________ ,Murmur ___________ Scoliosis

Development assessment------~-------------------------------­

Neurological assessment

Other disease history ________________________________________ _

History of accidents (dates)

Serious Injury (dates) ________________________________________ _

Taking any Medication Allergic to any Medication ____________________ _

Was child ever hospitilized? D Yes D No If yes, when?

Where? ____________ Why? ___________ Surgical Procedures? ___________ _

VISION: (check one) c glasses

s glasses

HEARING

RIGHT LEFT

___ Acuity

____ Muse. Bat.

Fusion

Plus Lens

1000

FAILURE +-

TB Screening (Mantoux Test)

FAR R L

2000 4000

PASSING IS AT 25 DB

Date: Tested Read Result (MM)

Any reason the child should not take physical training? (If yes, doctor certificate is required).

Remarks:

NEAR R L

5000

Doctor's Signature _______________________ Date _____________ _

Note: Doctor, please attach your prescription blank stating that you have examined the above child and a copy of the immunization record.

M-41 REV. 4/04 (5)

\1Ji:WUIRE.0 M~DlCAL 9£FICE STAMP) @": "R"'E:o,zun;r""·~-""·~·F'E"S""E:F;L,l"'.O"'c"'o""N;:-t,s~u"'t".J""'o"",A_""io""M<7 ...•••• :aED"'J""Cc>:O,.:..,jl

Parental/Guardian Consent Form

We are sending you this parental consent form to both inform you and to request perm1ss1on for your child's photo/image and personally identifiable information to be published on the district and/or school's web site.

As you are aware, there are potential dangers associated with the posting of personally identifiable information on a web site since global access to the Internet does not allow us to control who may access such information. These dangers have always existed; however, we as schools do want to celebrate your child and his/her work. The law requires that we ask for your permission to use information about your child.

Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes student names, photo or image, residential addresses, e-mail address, phone numbers and locations and times of class trips.

If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the principal of your child's school and such rescission will take effect upon receipt by the school.

Check one of the following choices:

0 1/We GRANT permission for a photo/image that includes this student without any other personal identifiers to be published on the school and/or district's public Internet site.

0 1/We GRANT permission for this student's photo/image and name to be published on the school and/or district's public Internet site.

0 1/We GRANT permission for this student's photo/image and all other personal identifiers listed above to be published on the school and/or district's public Internet site.

0 1/We DO NOT GRANT permission for photo/image that includes this student to be published on the school and or district's public Internet site.

Student's Name: (please print) ------------------ Student's Grade: __ _

Print name of Parent/Guardian: (print)---------------------------

Signature of Parent/Guardian: (sign) --------------------------

Relation to Student:--------------------------------

Dffie: __________ __