Region 15 Student Registration Form

Student Information

Last Name:

First Name:

Middle Name:

"Nick name" (if applicable):

Home Phone: unlisted
--

Sex:
Male Female

Current Grade:

Social Security Number:
--

Physically Handicapped:
Yes No

Special Education:
Yes No

If in Special Education, is there a current IEP?
Yes No

Birthplace: (City, State)

Other: (City, Country)

Date of entry into the US:

Birthdate: (mm,dd,yyyy)

Verification of Birth date:
Birth Certificate
Passport
Baptismal Certificate
Transfer Record

Racial Ethnic:
American Indian or Alaskan Native
Asian American or Pacific Islander
Black not of Hispanic Origin
White not of Hispanic Origin
Hispanic

Student Primary Address:
Street Address
Address (cont.)
City
State
Zip Code

Mailing Address (if different from primary address):
Street Address
Address (cont.)
City
State
Zip Code

Student Resides With:
Parents
Mother
Father
Mother/Stepfather
Father/Stepmother
Foster Parent(s)
Grandparent(s)
Guardian(s) (specify relationship):

Brother/Sister Family Information:
Name:	Birthdate:	Enrolled?

Previous School Information

Last School Attended:
Street Address
City
State
Zip Code
Phone
Fax

Date Left:

Last Grade Completed:

Grades Repeated (if any):

Did your child attend Preschool, Nursery School or Headstart?
Yes No

Dominant Language Survey:

What language did your child learn to speak first?

What is the primary language spoken by you or the child's primary care giver?

What is the primary language spoken by your child when he/she is home?

Primary Language (office use only)

Family Information:

Have you been granted legal custody of this child through court procedure? (If yes, we request a copy of the court decree for our files for the protection of your child from non-custodial parents.)

Yes
No

Resides With (first adult)
Full Name:
Street Address:
City:
State:
Zip Code:

Home Phone #:

Cell Phone #:

Email:

Employer:

Occupation:

Work Phone #:

Relation to Student:

Resides With (second adult if applicable)
Full Name:
Street Address:
City:
State:
Zip Code:

Home Phone #:

Cell Phone #:

Email:

Employer:

Occupation:

Work Phone #:

Relation to Student:

Non-resident Father (if applicable):
Full Name:
Street Address:
City:
State:
Zip Code:

Home Phone #:

Cell Phone #:

Email:

Employer:

Occupation:

Work Phone #:

Relation to Student:

Non resident Mother (if applicable):
Full Name:
Street Address:
City:
State:
Zip Code:
Relation to Student:

Home Phone #:

Cell Phone #:

Email:

Employer:

Occupation:

Work Phone #:

Health, Medical and Emergency Contact Information

Is there any medical information concerning your child that we should know that will assist us in planning his/her program? (allergies, etc.)

Student's Physician Name:	Phone#:	Choice of Hospital:
1.
2.
Student's Dentist:	Phone#:
1.

Local Emergency Contacts (other than parents/guardians):
Name:	Relationship:	Home Phone#	Work Phone#	Cell Phone#
1.
2.
3.

Other Information (OFFICE USE ONLY)

Verification of Residency:

Mortgage	Rental Agreement	Utility Bill	Bill of Sale (date):	Legal Guardianship	Other:
Notarized Affidavit (including copy of driver's license, car registration and tax bill- these items must show the family's name at a Middlebury or Southbury address).

Student ID #: School Code: Grade:

Homeroom #: Counselor Code:

Original Date of Entry: Date of Re-Entry:

*A completed physical health form (required by the State of Connecticut): Yes No

To the best of my knowledge all of the information is accurate:

Parent/Guardian Signature:

_____________________

Date:

___________________

School Interviewer Signature:

______________________

Date:

____________________

Reg Doc-April 25, 2005 (For best printing results, please set all margins in your web browser's page setup to .25")