PO Box 124, 115 Brickman Road Fallsburg, NY 12733 845-434-5884 Fax: 845-434-8346 Web: www.fallsburgcsd.net

Welcome to the Fallsburg Central School District! Registration Check List

Student’s Name ______________________________________________ Date _________________________ In order to complete your child’s registration you must provide the following:

____Birth Certificate/Passport ____Record of Immunizations ____Proof of Residency: current signed lease, school tax bill, pay stub, current utility bill that shows where the service is located (propane, oil, electric, home phone, cable, water/sewer etc.) or legal affidavit of residency (available upon request.) ____Custody document/ Guardianship affidavit (if applicable) ____Picture ID for parent (license, passport, work identification etc.) ____Name, address, phone# and fax# of school previously attended.

To complete your child’s registration please call: 845-434-6800 ext 1222. You may fax the above mentioned documents to 845-434-0418 Attn: Sarah Ungerleider

Prepare Today: Succeed Tomorrow: Inspire Excellence: Challenge the World

Fallsburg Jr. /Sr. High School PO Box 124 115 Brickman Road Fallsburg, NY 12733 Voice: 845-434-6800 Fax:845-434-0168

Benjamin Cosor Elementary School PO Box 123 I 5 Old Falls Road Fallsburg, NY 12733 Voice: 845-434-4110 Fax: 845-434-0871

Guidance Office PO Box 124 115 Brickman Road Fallsburg, NY 12733 Voice: 845-434-6124 Fax: 845-436-0207

Pupil Personnel Services PO Box 124 115 Brickman Road Fallsburg, NY 12733 Voice:845-434-0467 Fax: 845-434-0418

List of Acceptable Documents All documents must be unexpired Acceptable Documents to Prove Identity and Age: Original or certified copy of birth certificate

Passport

Certification of Birth Abroad or Report of Birth issued by the Dept. of State.

Driver’s license or ID card issued by a State or outlying possession with photograph and

information such as name, birth date, gender, height, eye color and address.

US Citizen ID or Permanent Resident card

ID card issued by federal , state or local government agencies or entities with photograph and

information such as name, birth date, gender, height , eye color and address.

School ID card with a photograph.

Voter’s registration card

US Military card or draft record

Military dependent’s card

US Coast Guard Merchant Marine card

Native American tribal document

Driver’s license issued by a Canadian government authority

For person’s under age 18:

School record or report card

Clinic, doctor or hospital record

Day-care or nursery school record

Proof of Residency: a document that lists the physical address of a student. Pay stub

Income tax form

Property or School tax bill

Deed or lease to a house or apartment that names parent or legal guardian as owner or tenant

Utility (electric, telephone, fuel oil or gas, television or internet) bills or other bills that reference

the physical address and names one of the parents or legal guardians as the customer

Voter registration document

Affidavit of Residency available upon request

Fallsburg Central School District

Parent/Guardian Signature ___________________________ Date _______________________

Registration Form Student Information:

Student’s Legal Name First Middle Last Gender M F

Date of Birth Country of Birth Date First Entered US Date First Entered US Schools

Current Address Zip Code

Name of Person Who Owns/Leases the Current Residence Home Telephone Number

Mailing Address (if different from above) Zip Code

What is the student’s native language? Is English spoken in the home? Yes No

Parent/Guardian Information: Full Name Relationship to Child Employer

Address (if different from student’s address) Lives with student? Yes No

Authorized Pick-up? Yes No Should receive mail? Yes No

Cell Phone Number Work Phone Number Email Address Parent/Guardian Information: Full Name Relationship to Child Employer

Address (if different from student’s address) Lives with student? Yes No Authorized Pick-up? Yes No Should receive mail? Yes No

Cell Phone Number Work Phone Number Email Address Emergency Contact Information: (other than parent) 1. Name Relationship to Child Phone Number Authorized Pick-up Yes No 2. Name Relationship to Child Phone Number Authorized Pick-up Yes No 3. Name Relationship to Child Phone Number Authorized Pick-up Yes No 4. Name Relationship to Child Phone Number Authorized Pick-up Yes No 5. Name Relationship to Child Phone Number Authorized Pick-up Yes No

Fallsburg Central School District

Parent/Guardian Signature ___________________________ Date _______________________

Please list all other people living in your home including other adults and children.

Name Relationship to student Gender Age (if child) Grade (if child)

Additional Information: Please check any of the following things about your child or family that you would like school staff to be aware of so we can better serve you.

I have a custody agreement. Please provide legal documentation. There is a visitation agreement on file. Please provide legal documentation. Another legal agreement, such as restraining order or order of protection is on file. Please explain

below and provide documentation. My child has a health condition (please describe) Ethnicity and Race 1. Is the student you are registering Hispanic or Latino? Yes No

2. What is the student’s race? (Please check all that apply; at least one box must be checked) American Indian or Alaska Native: A person having origins in any of the original peoples of North and

South America (including Central America,) and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.

Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

Black or African American: A person having origins in any of the Black racial groups of Africa. White: A person having origins in any of the original peoples of Europe, North Africa or the Middle

East.

Student Name

Fallsburg Central School District

Parent/Guardian Signature ___________________________ Date _______________________

Previous Schools Attended (Please list all previous schools student has attended with the most recent school listed first.) School Name School City/State Phone# Grade Levels

School Name School City/State Phone# Grade Levels

School Name School City/State Phone# Grade Levels

School Name School City/State Phone# Grade Levels In the previous school, did the student receive any of the following services? Please select all that apply. (Your answers ensure that your child is placed in the proper setting)

Speech/Language Math Support Reading Support

Tutoring Counseling English as a Second Language

Occupational Therapy Physical Therapy

Special Education Classroom or Services

Other (please explain) Has the student had an education evaluation? Yes No If yes, does the student have a: Current IEP 504 Accommodation Plan Has the student attended the Fallsburg Central School District previously? Yes No If yes, for what grades? Has the student been continuously enrolled in school? Yes No If no, please explain. Has the student ever repeated a grade? Yes No If yes, what grade(s)? Has the student ever had ESL instruction in a New York State school? Yes No If yes, when?

Please use this space to share any academic, social, emotional or family concerns you feel are important regarding your child. This information will help us make his or her school experience the best it can be.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Student Name

ENROLLMENT FORM - RESIDENCY QUESTIONNAIRE

Name of LEA: Fallsburg Central School District LEA Liaison: Heather Hendershot Name of Student:

Last First Middle Gender: Male Date of Birth: / / Grade: ID#: Female Month Day Year (preschool-12) (optional) Address: Phone:

The answer you give below will help the district determine what services you or your child may be able to 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 don’t have the documents 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? (Please check one box.)

In a shelter With another family or other person because of loss of housing or as a result of economic hardship

(sometimes referred to as “doubled-up”) In a hotel/motel In a car, park, bus, train, or campsite Other temporary living situation (Please describe):

In permanent housing

Print name of Parent, Guardian, or Signature of Parent, Guardian, or Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth) Date

NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a Designation Form is completed.

FALLSBURG CENTRAL SCHOOL DISTRICT PO Box 124, 115 Brickman Road

Fallsburg, NY 12733 Voice: 845-434-5884 Fax: 845-434-0418

Web: www.fallsburgcsd.net

PARTNERSHIPS

KEY TO EXCELLENCE

Fallsburg Jr./Sr. High School Benjamin Cosor Elementary School Guidance Office Pupil Personnel Services PO Box 124 PO Box 123 PO Box 124 PO Box 124

115 Brickman Road 15 Old Falls Road 115 Brickman Road 115 Brickman Road Fallsburg, NY 12733 Fallsburg, NY 12733 Fallsburg, NY 12733 Fallsburg, NY 12733 Voice: 845-434-6800 Voice: 845-434-4110 Voice: 845-434-6124 Voice: 845-434-0467

Fax: 845-434-0168 Fax: 845-434-0871 Fax: 845-436-0207 Fax: 845-434-0418

Together, we will make a difference

RELEASE FORM Re: ___________________________________________ DOB:_______________

(Student Name) I hereby authorize _______________________________________________ (Name of Organization) _______________________________________________

(Address) _______________________________________________ (Town, State, Zip) ____________________________ ______________________ (Phone) (Fax)

to forward all educational, medical, social, and / or psychological records to: _______________________________________________ (Name of Organization) _______________________________________________

(Address) _______________________________________________ (Town, State, Zip) ____________________________ ______________________ (Phone) (Fax)

It is my understanding that these records are for professional use only and will be kept in a confidential file.

Parent / Guardian Signature: ________________________________________________ Print Name: __________________________________________ Date: ____________

Prepare Today: Succeed Tomorrow: Inspire Excellence: Challenge the World

FALLSBURG CENTRAL SCHOOL DISTRICT PO Box 124, 115 Brickman Road

Fallsburg, NY 12733 Web: www.fallsburgcsd.net

REQUEST FOR RECORDS

Attn: Records Secretary

Student: ___________________________________________ Date: ___________________ Date of Birth: ____________________ Grade: _________________

The above named student has enrolled in the Fallsburg Central School District. Kindly forward the following records to us as noted:

___ URGENT: To complete the registration process, please fax the Birth Certificate and Immunization records to 845-434-0418. If they are not available, please call 845-434-6800, ext. 1222. Thank You!

___Elementary: School records, health records (including copies of last physical and vision and hearing screenings, as well as NYS required immunizations), semester or quarterly grades, NYS assessment results (including LAB-R and ESL / NYSESLAT scores and dates of service), standardized test scores, grades at time of withdrawal, and attendance records to:

Benjamin Cosor Elementary School PO Box 123 Phone: 845-434-4110 Fallsburg, NY 12733 Fax: 845-434-0871

___ Middle School/ High School: student transcript that includes grades and credits to date, health records (including copies of last physical and vision and hearing screenings, as well as NYS required immunizations), semester or quarterly grades, NYS assessment results (including LAB-Rand ESLINYSESLAT scores and dates of service), standardized test scores, science labs, grades at time of withdrawal, and attendance records to:

Fallsburg High School Guidance Department PO Box 124 Phone: 845-434-6800 ext. 2208 Fallsburg, NY 12733 Fax: 845-434-2523

___ CSE/CPSE: IEP, medical, social history, neurological, psychological, psychiatric, academic reports, and any related services reports (i.e. OT, PT, Speech, Counseling) etc. to:

Fallsburg Central School District Pupil Personnel Services

PO Box 124 Phone: 845-434-0467 Fallsburg, NY 12733 Fax: 845-434-0418

Fallsburg is an IEP Direct School. If you are an IEP Direct School please

electronically forward the IEP. Thank you. Name of previous school: Fax (school) Address of previous school: Fax (special Ed) Phone number of previous school: Parent/Guardian Signature

Fallsburg Jr. /Sr. High School PO Box 124 115 Brickman Road Fallsburg, NY 12733 Voice: 845-434-6800 Fax: 845-434-0168

Benjamin Cosor Elementary School PO Box 123 I 5 Old Falls Road Fallsburg, NY 12733 Voice: 845-434-4110 Fax: 845-434-0871

Guidance Office PO Box 124 115 Brickman Road Fallsburg, NY 12733 Voice: 845-434-6124 Fax: 845-436-0207

Pupil Personnel Services PO Box 124 115 Brickman Road Fallsburg, NY 12733 Voice: 845-434-0467 Fax: 845-434-0418

Fallsburg Jr./Sr. High School Benjamin Cosor Elementary School Guidance Office Pupil Personnel Services PO Box 124 PO Box 123 PO Box 124 PO Box 124 115 Brickman Road 15 Old Falls Road 115 Brickman Road 115 Brickman Road Fallsburg, NY 12733 Fallsburg, NY 12733 Fallsburg, NY 12733 Fallsburg, NY 12733 Voice: 845-434-6800 Voice: 845-434-4110 Voice: 845-434-6124 Voice: 845-434-0467 Fax: 845-434-0168 Fax: 845-434-0871 Fax: 845-436-0207 Fax: 845-434-0418

Prepare Today : Succeed Tomorrow : Inspire Excellence : Challenge the World

FALLSBURG CENTRAL SCHOOL DISTRICT PO Box 124, 115 Brickman Road

Fallsburg, NY 12733 Voice: 845-434-5884

Fax: 845-434-0418 Web: www.fallsburgcsd.net

Request for Medical Records

Student: DOB: GRADE: The above named student has registered at the Fallsburg Central School District. Please forward all health records (including copies of the last physical, vision and hearing screenings as well as NYS required immunizations) to the appropriate nurse’s office, thank you.

Benjamin Cosor Elementary School for grades Pre-K through 6: FAX # 845-434-0871 ATTN: Ms. Hobby

Jr./Sr. HS for grades 7 through 12: FAX # 845-434-3821 ATTN: Ms. Lindsey

Name of previous school: Address of previous school:

_ Phone number to previous school: Fax number to previous school:

X Parent/Guardian Signature Date:

FALLSBURG CENTRAL SCHOOL DISTRICT HEALTH HISTORY

Name: ________________________________________________ Date: ______________ Grade: _________

Name of Previous School: ______________________________ Date of Birth: ___________ Sex: M F

Name of Family Physician: _____________________________________ Phone: ______________________

Name of Family Dentist: _______________________________________ Phone: ______________________ Please check and include dates if your child has had any of the following: _____ chicken pox ___________________________________ _____ diphtheria _____________________________________ _____ German measles _______________________________ _____ mumps _______________________________________ _____ pneumonia ____________________________________ _____ asthma _______________________________________ _____ strep throat ___________________________________

_____ whooping cough _______________________________ _____ diabetes ______________________________________ _____ heart disease __________________________________ _____ kidney disease _________________________________ _____ blood disease __________________________________ _____ head injury ____________________________________ _____ other: ________________________________________

_____ episodes of unconsciousness or fainting ____________________________________________________________________ _____ frequent colds and sore throats___________________________________________________________________________ _____ frequent ear infections or hearing problems _________________________________________________________________ _____ operations or serious accident ____________________________________________________________________________

___ Yes ___ No During pregnancy did the mother have any illness or medical problems?

___ Yes ___ No Was the baby healthy at birth? If no, please explain birth problems / treatments: _________________ ____________________________________________________________________________________

___ Yes ___ No Has your child ever had a temperature of over 103 for more than 2 days?

___ Yes ___ No Has your child ever had seizures? If yes, at what age? ____________ febrile or unknown cause?

___ Yes ___ No Does your child wear glasses or contacts, have an eye defect, or evidence of vision problems? Please explain: ____________________________________________________________________________

___ Yes ___ No Does your child have any allergies? If yes, what type / kind? __________________________________

___ Yes ___ No Does your child need an epipen?

___ Yes ___ No Has your child had any serious injury or hospitalization in the last year? If yes, please explain: _______ ____________________________________________________________________________________

___ Yes ___ No Has your child had a fracture or dislocation? Details: _________________________________________ ___ Yes ___ No Has a family member had any serious or chronic illness? (i.e.: tuberculosis) If yes, who, what? ______

____________________________________________________________________________________ ___ Yes ___ No Does your child have any health problems that we should be aware of? If yes, please explain: _______

____________________________________________________________________________________ ___ Yes ___ No Is your child taking medication on a regular on-going basis? (including medication given only at home)

If yes, please give details: ______________________________________________________________ ____________________________________________________________________________________

Are there any other serious health problems / information that you would like to add? (please include dates) ___________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

___ Yes

___ No

Please have the nurse call me. I need to give her additional information.

I give permission for the school nurse to inform my child’s teachers of any medical condition that may need to be monitored in the classroom.

I understand that the nurse in my child’s school is requesting a visit with me prior to my child’s enrollment. X ______________________________

Signature of Parent / Guardian Phone Number(s)__________________________________________________________