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6.19
PLYMOUTH PUBLIC SCHOOLS
PROOF OF RESIDENCY
1.0 RESIDENCY
1.1 In order to attend Plymouth Public Schools, a student must actually reside in the Town of Plymouth. “Residence” is the place where a person dwells permanently, not temporarily, and is the place that is the center of his or her domestic, social, and civic life. This policy includes student acceptance into the Plymouth Public Schools Vocational Technical Education Programs. Temporary residence in the Town of Plymouth, solely for the purpose of attending a Plymouth public school, shall not be considered residency.
1.2 The residence of a minor child is presumed to be the legal residence of the parent(s) or guardian(s) who have physical custody of the child. Any student 18 years or older may establish a residence apart from his or her parent(s) or guardian(s) for school attendance purposes.
2.0 RESIDENCY VERIFICATION
2.1 Families registering for the Plymouth Public Schools or submitting a change of address must demonstrate Plymouth residency by presenting one document from each of three categories in the following table:
All applicants must present at least one document from each column (A, B, and C) below. No document may be used twice as verification.
A. Verification of PlymouthAddress & SchoolDistrict
B. Verification of CurrentResidency At ThisAddress
C. Verification of Identity
Dated within the past 60 days:
- Letter from approvedgovernment agency
- Payroll stub
- Bank or credit cardstatement
- Copy of Deed OR recordof most recent mortgagepayment.
- Copy of Lease AND recordof most recent rent payment.
- Legal affidavit fromlandlord affirming tenancyAND record of most recentrent payment.
- Section 8 Agreement
A utility bill or work order dated within the past 60 days, including:
- Gas bill
- Oil bill
- Electric bill
- Home telephone bill
- Cable bill
-Valid driver’s license
-Current vehicle registration
-Valid Massachusetts photoidentification card
-Valid passport
Dated within the past year:
-W-2 Form
-Excise (vehicle tax bill
-Property tax bill
Dated within the past 60 days:
-Letter from approvedgovernment agency
-Payroll stub
-Bank or credit cardstatement
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6.19
PLYMOUTH PUBLIC SCHOOLS
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2.2 In order to verify residency, Plymouth Public Schools reserves the right to request additional documents and/or to conduct an investigation. Because residency can change for students and their families during the school year, Plymouth Public Schools may verify residency at any time.
2.3 All new applicants are required to present the required three proofs.
2.4 If you are a tenant at will (“month-to-month”) and do not have a written lease, ask your landlord to complete and sign the Landlord/Shared Tenancies Affidavit, available at the schools or online. This form must be notarized prior to submission.
2.5 The “Proof of Residency” policy does not apply to homeless students and families. Contact the office of Pupil Personnel Services (508-830-4300) for assistance with registering your child. If you are staying in a shelter, bring a letter from the shelter staff stating that you are living there.
Revision: Revision: Information: January 25, 2010 Information: May 3, 2010 Information: February 7, 2011 Discussion: January 25, 2010 Discussion: May 3, 2010 Discussion: February 7, 2011 Adopted: January 25, 2010 Adopted: May 3, 2010 Adopted: February 7, 2011
Plymouth Public Schools Plymouth, Massachusetts
Student Registration Form
School: School Year: 2020-2021
Last Name:
First name:
Middle Name:
Gender: Yr. of Grad.
Grade: Homeroom:
SASID #:
Enrollment Date: Former School/School Address: Has student ever been enrolled in a Massachusetts school? YES NO If YES, where:
Has student ever been enrolled in Plymouth? YES NO If YES, where:
Has student taken Gr. 10 MCAS: Math ELA Science If so, where:
Student’s Mailing Address: Street/P.O. Box Town Zip
Student’s Home Address: Street/P.O. Box Town Zip
Is the student homeless: YES NO Home Telephone Number:
Mother’s Name: Live with: Yes No Mother’s address (if different from “home address”):
Mother’s Place of Work: Mother’s Work/Cell Phone No.: Mother’s Home Phone (if different from “home phone”):
Father’s Name: Live with: Yes No Father’s address (if different from “home address”):
Father’s Place of Work: Father’s Work/Cell Phone No.: Father’s Home Phone (if different from “home phone”):
Mother’s Email: Father’s Email:
Guardian: Mother Father Both Other > May child be dismissed to either parent? YES NO
Name: Relationship: Are there any legal issues or dismissal restrictions that the school should be aware of? YES NO If YES, a copy MUST be on file in the School Office.
Birth Date: City-State-Country of Birth: U.S. Citizen: YES NO(mm/dd/yyyy)
IN AN EMERGENCY, NOTIFY / DISMISS TO: (First) IN AN EMERGENCY, NOTIFY / DISMISS TO: (Third) Name: Name:
Phone: Phone:
Relationship: Relationship:
IN AN EMERGENCY, NOTIFY / DISMISS TO: (Second) IN AN EMERGENCY, NOTIFY / DISMISS TO: (Fourth) Name: Name:
Phone: Phone:
Relationship: Relationship:
Information below is required by the Massachusetts Department of Education (please check each appropriate answer).
Is English the first (native) language of the student? YES NO Ethnicity: Is the student either Hispanic or Latino? Is the student capable of performing ordinary classwork in English? YES NO YES NO If not, what is the child’s primary language (spoken most often at home)?
Race (check one or more below):
Is the student currently on an Individual Education Plan? YES NO White
Is the student currently on a 504 Plan? YES NO Black or African American
Are there any court actions pending against the student? YES NO Pacific Islander
Is the student currently suspended? YES NO American Indian or Alaskan Native
Is the student expelled? YES NO Asian
Signature of Parent/Guardian: Date:
H:\Forms\F StdntRegistration 2-16-10.doc
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Note: this form provides information about your child’s health history and health care. This information is confidential and will be maintained in the
student’s school health record. If you do not understand a question or word, please ask for assistance.
First Name: Middle Name: Last Name:
Date of Birth: Place of Birth: Date of Last Physical:
Date of Last Dental Exam:
Primary Language:
Section One: Student Medical History
Does your child have a history of: (Select Yes or No) Diagnosis Yes No Yes No Diagnosis: Yes No
Allergies Headaches/Migraines Tobacco Use
Autism Spectrum Disorder
Respiratory Disorders /Asthma
Attention Deficit/ Hyperactivity Disorder
Other Conditions: Physical/Developmental
Current Medications/ Dose:
Section Two: Student Medical History (Select all that apply)
1. Does your child have a life threatening allergy YES NO a. Allergens:b. Does your child require an Epipen®? YES NO c. Allergist/Phone: /
2. Does your child:a. have asthma? YES NO b. use a maintenance inhaler? YES NO c. use a rescue inhaler? YES NO
3. Does your child have Cancer/Leukemia? YES NO a. Current Status: Under treatment In Remission b. Date of Diagnosis: Last Treatment Date: c. Oncologist/Phone: /
4. Has your child ever had a concussion? YES NO a. Date of Injury:b. Was your child seen by a physician? YES NO c. Was your child cleared to return to school/play/sports? YES NO d. Residual restrictions:
5. Does your child have:a. Insulin Dependent Diabetes? YES NO b. Use an: Insulin pump Pen Inject via syringe Continuous Glucose Monitor c. What type of insulin does your child use? Lantus Novolog Humalog Other: d. Endocrinologist/Phone: / e. Date/Result of last A1C level: /
6. Has your child had any recent fractures? YES NO a. Date/site of injury: / b. Any related restrictions:
7. Does your child have seizure disorder? YES NO a. Date of last seizure:b. Medications:c. Neurologist/Phone: /
Plymouth Public Schools Student Health History
Date:
Note: this form provides information about your child’s health history and health care. This information is confidential and will be maintained in the
student’s school health record. If you do not understand a question or word, please ask for assistance.
Student Name: Student Health History (Page 2)
Section Three: Student Surgical History (Complete as appropriate)
Diagnosis Date Diagnosis Date Diagnosis Date
Appendectomy Ear Tubes Heart Surgery
Tonsillectomy & Adenoidectomy
Adenoidectomy with PE tubes
Other:
Section Four: Student Mental/Behavioral Health/Emotional Concerns (Complete as appropriate) It is well documented that there is a connection between a child’s living environment, mental/emotional health, physical health and ability to succeed academically. Answering the following questions will help the school nurse advocate for your child’s day-to-day needs.
Diagnosis Yes No Hospitalizations
Dates Medications Case Workers/Counsellor
Alcohol Abuse
Anxiety
Depression
Drug Abuse
Mood Disorder
Oppositional Defiant Disorder
Post-Traumatic Stress Disorder
School Phobia
Other:
Do you have any questions or concerns regarding your child’s emotional and/or physical health issues that you would liketo discuss in private with your school nurse? Yes No
How should the nurse contact you to arrange a discussion?
Section Five: Family Health Concerns (Complete as appropriate)
Relationship
Alc
oh
ol
Ab
use
Ast
hm
a
Au
tism
Sp
ect
rum
Dis
ord
er
Can
cer
Dia
be
tes
Do
me
stic
Vio
len
ce
Dru
g
Ab
use
Earl
y
De
ath
He
arin
g
Loss
He
art
Dis
ea
se
Hig
h
Ch
ole
ste
rol
Hig
h B
loo
d
Pre
ssu
re
Kid
ne
y
Dis
ea
se
Lear
nin
g
Dis
abili
ty
Thyr
oid
Dis
ea
se
Mother
Father
Sister
Brother
Other
Other
Student’s Siblings
Name Birth Date Name Birth Date
Passive Smoke: Student Exposure to People Who Smoke
Tobacco: Never Yes In the Past
Packs/day:½ 1 2 3 or more
Years of Use: Less than 1 year 1-5yrs 5-10yrs Greater than 10 yrs.
If you answered yes: Smokes Inside Smokes outside only
Smokeless Tobacco (Chewing, Ecigarettes): Never Yes In the Past
Does the individual still use tobacco products? Yes No
Parent/Guardian (please print) Parent/Guardian Signature
Phone: Date:
TRANSPORTATION APPLICATION 2020-2021
For student record keeping, please submit even if your student is not using the bus.
For School Use Only:
Date Received
Stamp FOR GUARANTEED SEATING, PLEASE SUBMIT by June 30, 2020. Date Processed: By:
Entered in computer: By:
The Plymouth School Department requires payment of a bus fee for all students intending to use bus transportation for the 2020-2021 school year under the following guidelines: Massachusetts General Law CH. 71, S. 68, requires that school committees provide free transportation, once daily, to and from school for students in grades K-6 who live two (2) or more miles from their assigned schools. The statute further requires that students not be required to walk more than one (1) mile from their home to their assigned bus stop. Therefore, no bus fee will be charged for students in Grades K-6 residing two (2) or more miles from their assigned school. A BUS FEE WILL BE CHARGED for students in Grades K-6 residing less than two (2) miles from their assigned school, and all students in Grades 7-12, regardless of distance.In order to qualify for the advance payment discount and to guarantee a seat on the bus for your child, payment must be made on or before June 30, 2020. Fees paid after that date will be assessed at the REGULAR FEE RATE. The regular fee rate will be reduced by 50 percent (50%) for students enrolled after February 1st (the mid-year point of the school year). One-way bus passes may be purchased at 50 percent (50%) of the regular fee rate. AM or PM must be noted on application.
REGULAR FEE STRUCTURE REDUCED FEE *Families that are on TANF, eligible for SNAP, or meet Federal Income Eligibility Guidelines may apply for a waiver of fees. Bus applications should still be submitted.
PLEASE NOTE – A Massachusetts Free and Reduced Price School Meals Application MUST be filled out annually at the start of the year.
ADVANCE PAYMENT DISCOUNT RATE
On or before June 30, 2020
REGULAR FEE RATE Applies after June 30, 2020
Reduced/Free Eligible Rate*
For first student rider $100 $125 $00 For second student rider $ 75 $100 $00
For third student rider $ 50 $ 75 $00 Maximum per family $225 $300 $00
All rates subject to change.
Transportation applications are sent home with third-term report cards and are available thereafter at your child’s school. Bus fees are due in full with this application. PAYMENTS ARE NON-REFUNDABLE. Payments may be made by bank check, money order or personal check only. Personal checks returned for insufficient funds will be charged a $25 processing fee in addition to the bus fee.
NO CASH WILL BE ACCEPTED. Please make checks payable to: “TOWN OF PLYMOUTH – BUS FEE.”
APPLICATIONS and FULL PAYMENT SHOULD BE RETURNED TO ONE OF THE SCHOOLS WHERE YOU WILL HAVE A CHILD ATTENDING DURING THE 2020-2021 SCHOOL YEAR, making sure to include the school names where all other children are enrolled. A copy will be scanned to each school. Applications can be mailed to the school during the summer. Please visit http://www.plymouth.k12.ma.us for individual school addresses. Passes will be distributed in the fall.
Please complete one (1) application per family and include all students that will attend Plymouth Public or Charter Schools, even if no payment is due and/or student is not using bus transportation.
Parent/Guardian Name(s): Number of children in family attending Plymouth Schools:
Street Address: Home Phone:
Complete Mailing Address, if different: Cell/work Phone:
Please list names of all students in family, even if no payment is due. Please check one: For School Use Only
Student(s) Name(s) **School in 2020-21**
Grade in 2020-21
Will use bus
Will NOT
use bus
ALTERNATE transportation if not using bus
Elig. Amount Paid
Scanned to other schools
**Please provide school name where each student attends. This application will be scanned to all schools listed. **
PARENT/GUARDIAN SIGNATURE: DATE:
Plymouth Public Schools HOME LANGUAGE SURVEY
Plymouth Public Schools HOME LANGUAGE SURVEY [HAITIAN CREOLE]
Cc: Principal; Guidance Counselor Home Language Survey H:ELL\F-HmLangSrvy-English English Form
Español: Este es un documento importante. Por favor hágalo traducir. Póngase en contado con la escuela de
su niño si usted necesita ayuda. Gracias.
Português: Isto é um documento importante. Por favor mande-o traduzir. Contate a escola da sua criança se
você precisar de ajuda. Obrigado.
Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.
Student Information
F M First Name Middle Name Last Name Gender
Country of Birth Date of Birth (mm/dd/yyyy) Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information
______ Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade
Questions for Parents/Guardians
What is the native language(s) of each parent/guardian? (circle one)
(mother / father / guardian)
(mother / father / guardian)
Which language(s) are spoken with your child? (include relatives -grandparents, uncles, aunts,etc. - and caregivers)
seldom / sometimes / often / always
seldom / sometimes / often / always
What language did your child first understand and speak? Which language do you use most with your child?
Which other languages does your child know? (circle all that apply)
speak / read / write
speak / read / write
Which languages does your child use? (circle one)
seldom / sometimes / often / always
seldom / sometimes / often / always
Will you require written information from school in your native language? Y N
Will you require an interpreter/translator at Parent-Teacher meetings? Y N
Parent/Guardian Signature:
X Today’s Date: (mm/dd/yyyy)
TO BE COMPLETED BY QUALIFIED ELL PROGRAM STAFF MEMBER BEFORE PLACEMENT
Date / School
Enrlmnt: ______
Student’s First Name Student’s Family Name Age Birthdate Grade
____ _________ ____
Relationship of Person Completing Survey: Mother Father Guardian Date Student entered the
United States:
Other Specify:
RECOMMENDATION: Signature of ELL Staff Proficiency Testing to determine LEP status and Academic Records Review. Member: Certified/Qualified ELL staff must make this assessment/recommendation.
Sheltered English Immersion FLEP _____________________
Proficient – No Sheltered Immersion Program: Note that this decision must be made with a full assessment of student proficiency based on either local proficiency testing or academic records from the previous school district showing reclassification of student from LEP to
formerly LEP using multiple criteria. Qualified staff must conduct this assessment.
Plymouth Public Schools
Administration Building 11 Lincoln Street
Plymouth, MA 02360
Telephone: 508-830-4300 Fax: 508-746-1873
Web: www.plymouth.k12.ma.us
GARY E. MAESTAS, Ed.D. Superintendent of Schools
CHRISTOPHER S. CAMPBELL, Ed.D.
Assistant Superintendent
Administration and Instruction
PATRICIA FRY
Assistant Superintendent
Human Resources
GARY L. COSTIN, R.S.B.A.
School Business Administrator
Liability Release Form ~ 2020-2021
As a result of a recent school district insurance review, our insurance carrier has recommended that all participants in school sponsored activities that occur outside of the regular classroom have a signed waiver on file. Students will be unable to participate in such activities if a signed Liability Release Form is not on file. I, the undersigned ________________________of _______________________________, my child or ward, Parent, guardian, etc. Student’s name (first and last) a minor, do hereby consent to my child’s participation in voluntary athletic or recreation programs, field trips, or school sponsored activities of the Town or Public School of Plymouth.
I also agree to forever release the Town or Public School of Plymouth, the School Committee, and all their employees, agents, board members, volunteers and any and all individuals and organizations assisting or participating in voluntary athletic or recreation programs, field trips, or school sponsored activities of the Town or Public Schools (“the Releasees”) from any and all claims, rights of action and causes of action that may have arisen in the past, or may arise in the future, directly or indirectly, from personal injuries to my child or property damage resulting from my child’s participation in the Town or Public School of Plymouth voluntary athletic or recreation programs, field trips, or school sponsored activities. I also promise, to indemnify, defend, and hold harmless the Releasees against any and all legal claims and proceedings of any description that may have been asserted in the past, or may be asserted in the future, directly or indirectly, arising from personal injuries to my child or property damage resulting from my child’s participation in the Town or Public School of Plymouth voluntary athletic or recreation programs, field trips, or school sponsored activities. I further affirm that I have read this Consent and Release Form and that I understand the contents of this Form. I understand that my child’s participation in these programs is voluntary and that my child and I are free to choose not to participate in said programs. By signing this Form, I affirm that I have decided to allow my child to participate in the Town or Public School’s athletic or recreation programs, field trips, or school sponsored activities with full knowledge that the Releasees will not be liable to anyone for personal injuries and property damage my child or I may suffer in voluntary Town or Public School athletic or recreation programs, field trips, or school sponsored activities.
Parent Signature:
Parent Printed Name:
(Please print)
Parent or Guardian of:
Grade:
(Please print)
School:
Date:
Massachusetts Parental Notice for One Time Consent to Allow the School District
To Access MassHealth (Medicaid) Benefits
School District Name and Code: Plymouth Public Schools (02390000)
School/District Contact: Christine Freitas Telephone: 508-224-5043
Dear Parent/Guardian:
The purpose of this letter is to ask for your permission (also known as consent) to share information about your child with MassHealth. Local communities in Massachusetts have been approved to receive partial reimbursement from MassHealth for the costs of certain health-related services provided by the district to your child (or children). In order for your community to get back some of the money spent on services, the school district needs to share with MassHealth the following types of information about your child: name; date of birth; gender; type of services provided, when, and by whom; and MassHealth ID.
With your permission, the school district will be able to seek partial reimbursement for services provided by MassHealth, including, among others, a hearing test or eye exam; a school physical; occupational or speech or physical therapy; some school nurse visits; and counseling services with the school social worker or psychologist. Each year, the district will provide you with notification regarding your permission; you do not need to sign a form every year.
The school district cannot share with MassHealth information about your child without your permission. As you consider giving permission, please be advised of the following:
1. The school district cannot require you to sign up for MassHealth in order for your child to receive the health-related and/or special education services to which your child is entitled.
2. The school district cannot require you to pay anything towards the cost of your child’s health-related and/or special education services. This means that the school district cannot require you to pay a co-pay or deductible so that it can charge MassHealth for services provided. The school district can agree to pay the co-pay or deductible if any such cost is expected.
3. If you give the school district permission to share information with and request reimbursement from MassHealth: a. This will not affect your child’s available lifetime coverage or other MassHealth benefit; nor will it in any way
limit your own family’s use of MassHealth benefits outside of school. b. Your permission will not affect your child’s special education services or IEP rights in any way, if your child is
eligible to receive them.
c. Your permission will not lead to any changes in your child’s MassHealth rights; and
d. Your permission will not lead to any risk of losing eligibility for other Medicaid or MassHealth funded programs.
4. If you give permission, you have the right to change your mind and withdraw your permission at any time.
5. If you withdraw your permission or refuse to allow the school district to share your child’s records and information with MassHealth for the purpose of seeking reimbursement for the cost of services, the school district will continue to be responsible for providing your child with the services, at no cost to you.
I have read the notice and understand it. Any questions I had were answered. I give permission to the school district to share with MassHealth records and information concerning my child(ren) and their health-related services, as necessary. I understand that this will help our community seek partial reimbursement of MassHealth covered services.
Parent/Guardian Signature: Date: _________________
Child's Name: Date of Birth: SASID # (for district to add):
Child's Name: Date of Birth: SASID # (for district to add):
Child's Name: Date of Birth: SASID # (for district to add):
Add more children
Massachusetts DESE Mandated Form 28M/13 Revised June 2018