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Union-Endicott CSD New Student Registration Form Combined

Union-Endicott Central School District

Central Registration: 1100 East Main St, Endicott NY 13760 - 607-757-2346 or 607-757-3212

Welcome to the Union-Endicott Central School District,

The online registration process will give us the initial information we need to enroll your student. During this process you will be asked to securely upload the following documents that are needed for registration:

Proof of Birth (Birth Certificate or Passport)
Two proofs of residency in Union-Endicott (Board Policy 7130)
Parent/Guardian photo identification
Immunization records Required Immunizations
Custody papers (if applicable)

*If you have any question please contact registration at 607-757-2346 or 607-757-3212

Thank you for enrolling at the Union-Endicott Central School District!

Primary Parent/Guardian

Primary contact's first name *

Primary contact's last name *

Middle Initial

Primary contact's street number *

Primary contact's street name *

Primary contact's Unit/Apt/Lot number

Primary contact's city *

Primary contact's State *

Primary contact's ZIP code *

Mailing Address

Home Phone *

Primary contact's cell phone number *

Work Phone

Primary contact's email *

Primary Parent/Guardian Permissions *

Receives Mail
Parent Portal (must have valid email)
Can Pick Up Student

Spouse or Other Adult in the Home

First Name

Last Name

Middle Initials

Resident Address

Does your address need to remain confidential?

Yes

Mailing Address

Home Phone *

Cell Phone

Work Phone

Email *

Spouse or Other Adult in Home Permissions *

Receives Mail
Parent Portal (must have valid email)
Can Pick up student

Student Information

Student's first name *

Student's last name *

Student's middle name *

Students Date of Birth *

Hispanic *

Yes

Student's gender *

Student's race: *

White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander

Primary contact's relationship *

Spouse/Other Adult in the home is:

Does your child have:

IEP

504 Plan

Medicaid

If Medicaid chosen, what is the ID#:

Union-Endicott ReEntry? *

Yes

If Yes, building last attended:

Ann G. McGuinness (AGM)
Charles F. Johnson Jr. (CFJ)
George F. Johnson (GFJ)
Thomas J. Watson (TJW)
Jennie F. Snapp Middle School (JFS)
Linnaeus W. West Tiger Ventures (LWW)
Union Endicott High School (UEHS)

Student ID# (If Known)

Siblings:

Last Name	First Name	Middle initial	Date of Birth	Age	Gender	Indicate IEP, 504, or NONE

Emergency Contacts:

Last Name	First Name	Address	Phone number	Relationship to student

Primary Language *

Is there anything you would like us to know about this registration? (Homeschooling, special circumstances, etc.)

Participant Acceptance *

I understand that statements made in this form will be relied upon by the Union-Endicott Central School District. I swear/affirm that these statements are true under penalty of perjury, and I understand that filing of a false instrument and the theft of services from a government agency such as a school district may be punishable by New York State law. I further Acknowledge that making false statements in this affidavit may subject me to criminal prosecution.

I authorize the release of all information to school personnel (academic, health, and confidential) for the student whom I am registering in Union-Endicott Central School District.

Name

Submission Public, please sign Show me how

Clear

Home Language Questionaire:

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.

What language(s) is(are) spoken in the student's home or residence? *

If Other selected, please specify:

What was the first language your child learned? *

If Other selected, please specify:

What is the Home language of Parent 1? *

What is the Home Language of Parent 2? *

What is the Home Language of the Guardian(s)? *

What language(s) does your child understand? *

English
Other

If Other selected above, specify:

What language(s) does your child speak? *

English
Other
Does Not Speak

If Other selected above, specify:

What language(s) does your child read? *

English
Other
Does Not Read

If Other selected above, specify:

What language(s) does your child write? *

English
Other
Does Not Write

If Other selected above, specify:

Educational History

Indicate the total number of years that your child has been enrolled in school. *

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.

How severe do you think these difficulties are?

Has your child ever been referred for a special education evaluation in the past? *

Yes

*If referred for an evaluation, has your child ever received any special education services in the past?

Yes

If 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)

Does your child have an Individualized Education Program (IEP)? *

Yes

Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

In what language(s) would you like to receive information from the school? *

Date Completed *

Relationship to student: *

If Other selected above, specify.

I allow the collection of my signature for the Home Language Questionnaire *

Residency questionaire:

The answer you give below will help the district determine what services you or your child may 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 do not have the documentation 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? Choose one *

If you chose 'Other temporary living situation' please explain your living situation

I allow the collection of my signature for the Residency Questionaire *

Health Requirements:

New York State Public Health Law 2164 states that a principal or person in charge of a school shall not permit a child to be admitted to school unless a person in parental relation to the child furnishes the school with proof the child has received all required immunizations. Within 14 days, I will furnish the school with a certificate of required immunizations or my child will be subject to exclusion from school.

Immunization Requirements (within 14 days):

MMR (Measles, Mumps, Rubella) - 2 doses

DTap, DTP - 4-5 doses at appropriate intervals

Polio (Salk) - 3-4 doses at appropriate intervals

Varicella - 2 doses for all grades except for grades 5,11, and 12 which require only 1 dose.

Tdap - 1 dose, students in grades 6-12

Hepatitis B - 3 doses at appropriate intervals

Meningitis - 1 dose for students entering grades 7, 8, 9 and 12 (Note for grade 12 – must have dose after 16 years of age)

Physical Examination:

The New York State Education Law and Regulations also require that all new entrants to school receive a physical examination. A completed health form must be filled out and returned to the Health Office. The examination must be performed during the calendar year of the entrance date to school and must be signed by a licensed physician, Nurse Practitioner or Physician’s Assistant, who is authorized to practice medicine in New York State.

Ideally, your family physician should perform this examination. However, the school district is mandated by law to provide a physical examination of any pupil whose parents do not provide a report from a family physician. These physicals are scheduled throughout the school year. If a student does not appear for the examination at the time he/she is scheduled, they will not be eligible to attend school the following September and thereafter unless or until a signed physical form is received by the Health Office.

If you need further information, contact the Health Office in your student’s building.

I certify that I have read, understand and agree to the terms outlined in the above policy named "Union-Endicott Central School District - Health Requirements" *

Health Sheet:

Pregnancy/Birth History

Did mother have any health problems during this pregnancy or delivery? *

Yes

If "yes", Explain (including dates/or age of child)

Was child born more than 3 weeks early or late? *

Yes

If "yes", Explain (including dates/or age of child)

Was child less than 5 lbs. or more than 10 lbs. at birth? *

Yes

If "yes", Explain (including dates/or age of child)

Was anything wrong with child in the hospital nursery? *

Yes

If "yes", Explain (including dates/or age of child)

Did child or mother stay in hospital longer than usual for medical reasons? *

Yes

If "yes", Explain (including dates/or age of child)

Hospitalizations and Illnesses

Has child ever been hospitalized or had surgery? *

Yes

If "yes", Explain (including dates/or age of child)

Has child ever had a serious accident (broken bones, head injuries, falls, burns, poisoning, or car accident)? *

Yes

If "yes", Explain (including dates/or age of child)

Has child ever had a serious illness? *

Yes

If "yes", Explain (including dates/or age of child)

Health Problems

Does child have frequent sore throats? *

Yes

If "yes", Explain (including dates/or age of child)

Does child have frequent cough? *

Yes

If "yes", Explain (including dates/or age of child)

Does child have frequent urinary infections or trouble urinating? *

Yes

If "yes", Explain (including dates/or age of child)

Does child have frequent stomach pain, vomiting, or diarrhea? *

Yes

If "yes", Explain (including dates/or age of child)

Does child have difficulty seeing (squint, cross eyes, look closely at books)? *

Yes

If "yes", Explain (including dates/or age of child)

Is child wearing (or supposed to wear) eye glasses? *

Yes

If "yes", Explain (including dates/or age of child)

Does child have problems with ear/hearing (pain in ear, frequent earaches, discharge, rubbing or favoring one ear) *

Yes

If "yes", Explain (including dates/or age of child)

Has child ever had a convulsion or seizure? *

Yes

If "yes", Explain (including dates/or age of child)

Is child taking medications for seizures? *

Yes

If "yes", Explain (including dates/or age of child)

Is child taking any Medications currently? (special consent form must be signed to administer any medication at school.) *

Yes

What medicine(s)?

If "yes", will it need to be given at school? how often?

Who is your child's Doctor? *

Dentist?

Is child now being treated by a physician and/or dentist? if yes what for? *

If "yes", Explain (including dates/or age of child)

Does your child have any allergy problems (rash, itching, swelling, difficulty breathing, coughing, sneezing? *

Yes

Food allergy

Medication allergy

Environmental allergy

I allow the collection of my signature for the Health Sheet form. *

Record Release:

It is requested that an official copy of the school records of the following student be released or transferred. The union undercut central school district forwards educational records upon request to any school or agency in which a student seeks or intends to enroll.

Name of Prior School *

Street Name and Number of Prior school *

City, State and Zip of Prior school *

Prior Schools Phone number *

Fax number of Prior School

Email of Prior School

Receiving School or Department:

Which school to send records to? *

Relationship to student *

Yes, I give my consent for the prior school to release records to the Union Endicott School District. *

Attachments:

Below you will attach any documents you have pertaining to the registration. Only the Proof of Birth and two Proofs of Residency are required at the time of registration. The other attachments are if you have them.

Some guidelines for submissions:

Proof Of Birth:

-Birth Certificate

- Passport

- Learner's Permit/Drivers license

Proof of Address:

-Utility or other bill (NYSEG, Spectrum, or a garbage service).

-Voter registration

-Car/ renters/ homeowners insurance.

-Pay stub

-Tax form

-Bank statement

-Documents issued by federal, state, or local agencies (such as from a local social services agency).

-Evidence of custody of the child, including but not limited to judicial custody orders or guardianship papers.

-Official driver’s license, learner's permit, or non-driver Identification.

-Membership documents based on residency

Proof of Birth *

List of Allowed file types

First Proof Of Address *

List of Allowed file types

Second Proof of Address (must be different) *

List of Allowed file types

Photo ID

List of Allowed file types

Immunizations

List of Allowed file types

Custody Documents

List of Allowed file types