Child s Name. Affidavit of Student Residency... Birth Certificate... Emergency Information Card... Home Language Survey...

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1 BURGESS ELEMENTARY SCHOOL 45 Burgess School Road, Sturbridge, MA Main Phone /Nurse Phone Main Fax: /Nurse Fax: Transfers into Grades K-6 Checklist Child s Name Affidavit of Student Residency... Birth Certificate... Emergency Information Card... Home Language Survey... IEP (Individual Educational Plan) if applicable... Letter of Discipline Status (from previous school) stating whether or not child has been suspended or expelled... Physical Exam (recent) and Immunization Record... Proof of Residency... Registration Form... Report Card... Request for records release - sign and date bottom portion only... Massachusetts Transfer Card if applicable (from previous school)... Your child will be admitted to school when all of the above are completed.

2 BURGESS ELEMENTARY SCHOOL MARY F. JAEGER KATHLEEN E. PELLEY 45 BURGESS SCHOOL ROAD ASSISTANT PRINCIPAL PRINCIPAL STURBRIDGE, MA JACK CANAVAN TELEPHONE ASSISTANT PRINCIPAL FAX (508) Registration Form Student s Name: Year of Grad: Date of Birth: Street Address: Student is entering grade: Date: First Middle Last Suffix Grade Level: City of Birth: City/State Zip Code Town of Residence Mailing if different: Phone: Unlisted? yes no Gender: Mother s Name: Title First Last Workplace: Gender: Legal Status (choose one) Custodial parent, Non custodial parent, Foster parent, other(specify): Does this guardian have the right to dismiss the student? yes no Does this guardian have the right to receive the student? yes no Does this guardian live with the student? yes no Does this guardian receive student s mail separately? yes no Street Address: Mailing if different: Home phone: Work phone: City/State/Zip Cell phone: Pager: Father s Name: Title First Last Workplace: Gender: Legal Status (choose one) Custodial parent, Non custodial parent, Foster parent, other(specify): Does this guardian have the right to dismiss the student? yes no Does this guardian have the right to receive the student? yes no Does this guardian live with the student? yes no Does this guardian receive student s mail separately? yes no Street Address: Mailing if different: Home phone: Work phone: City/State/Zip Cell phone: Pager: 1

3 Please list other children in the household: NAME Date of Birth Grade Emergency Contact: Relationship to student: Name: Address: Home phone: Cell: Emergency Contact: Relationship to student: Name: Address: Home phone: Cell: ************************************************************************ Please answer BOTH questions 1 and Is this student Hispanic or Latino? (choose only one) No, not Hispanic or Latino Yes, Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.) 2. What is the student s race? (choose one or more) 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 including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.) Black or African American (A person having origins in any of the black racial groups of Africa.) Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) 2

4 Military Family Status this student is a child of (PLEASE CHECK ONE): An active duty member of the uniformed services, National Guard and Reserve on active duty orders A member or veteran who is medically discharged or retired within one (1) year A member who has died on active duty Does not apply School Transferred From Name Street/PO Box City/State/Zip Code Will your child be entering this school with: An IEP? Yes No A 504 Plan? Yes No Remedial services in math? Yes No Remedial services in reading? Yes No Does your child currently receive occupational therapy services? Yes No Does your child currently receive physical therapy? Yes No Does your child currently receive speech services? Yes No Child is left handed Child is right handed If there is a restraining order or any other custody concern, please provide the school with a copy of a court document. ************************************************************************ PUBLICITY RELEASE On occasion, there will be publicity concerning your child s school program. We would like your permission to release your child s photograph/video in conjunction with such publicity. I give permission to release a photograph/video and name of my child for school related publicity at Burgess Elementary School. I don t give my permission to release a photograph/video and name of my child for school related publicity at Burgess Elementary School. Child s Name Parent s Signature Date ********************************************************************** FOR OFFICE USE Homeroom Bus In Address Bus Out Address 3

5 HEALTH INFORMATION ************************************************************************ Student s Name Please report any health problems that your child has such as allergies, operations, illnesses or injuries and the dates. (Please state if there are no health problems.) Medical Special Needs: Please describe any physical conditions your child has that we should be aware of or updated about (scoliosis, epilepsy, diabetes, asthma, chronic illness, glasses or hearing problems). Medication Profile: Please list any medications that your child is presently taking at home. If your child needs medication while in school, please contact the Health Office for the proper medication form. If you have any questions, please call Lisa Meunier, School Nurse at Thank you for your cooperation and prompt response regarding this matter. Lisa Meunier, School Nurse HEALTH INFORMATION PERMISSION FORM I give the nurse permission to share this information with appropriate school personnel thereby improving my child s total level of wellness regarding their health and safety. Parent/Guardian Signature Date 4

6 5

7 Report Card Please provide us with a copy of your child s most recent report card from the previous school your child attended.

8 SIGN AND DATE BOTTOM OF THIS FORM ONLY Dear Principal, has registered in our school as of _. In order to better serve the needs of the pupils, we feel we should have the following information from you: Transfer Card Health Record Cumulative Record Special Reports and Test Results (including any Chapter 766 reports, testing and educational plans) Letter of discipline status* (MGL Ch. 71 Sec. 37L) Any additional information not listed here, which is available, would be appreciated. Thank you very much for your cooperation. Sincerely, Kathleen E. Pelley I hereby give my permission to furnish to Burgess Elementary School full records and pertinent information concerning: Child s Name Parent/Guardian s Signature Date *Letter must include any record of prior suspensions or expulsions, or a statement that there is no record of any such actions, signed by a school official.

9 Massachusetts Transfer Card if applicable Please have your child s previous school provide you with a completed Massachusetts Transfer Card if you are transferring from a public school in Massachusetts.

10 METHOD OF COMMUNICATIONS Dear parent/guardian, A goal of Burgess Elementary school is to decrease the amount of paper notices going home in children s backpacks. We send the Parent/Student Handbook, Monthly Calendar of Events, the Breakfast and Lunch Menus, and other communications to as many parents we can via . We will be using the addresses provided by you on your child s registration form. Thank you. Check here if you do NOT wish to receive this information via and would like to receive them in your youngest child s backpack. (Please fill out below only if you check above.) Youngest Child s Name Homeroom

11 Tantasqua Regional/Union 61 School Districts Affidavit of Student Residency Please initial each box. I/we are the parent(s) or legal guardian(s) of and wish to enroll the above named student Print student's full name in School District Print district name I/we understand that pursuant to the laws of the Commonwealth of Massachusetts and the policy of the Tantasqua Regional/ Union 61 School Districts that only students who actually reside in the towns of Brimfield, Brookfield, Holland, Sturbridge, and Wales may attend district schools. I/we hereby certify that the above named student is/will be residing at the following address: Physical street address number/apt/unit Physical town of residence Effective Date Home Telephone Cell Telephone Alternate Telephone I/we acknowledge that I am/we are required to notify the Tantasqua Regional/Union 61 School Districts or the above student's school in writing of any change in said student's address within five (5) calendar days of such change of address. I/we understand that this Residency Statement will be relied upon by the Tantasqua Regional/Union 61 School Districts for the purpose of determining the above student's eligibility to attend the district schools on the basis of residency. If said student is enrolled in the Tantasqua Regional/Union 61 Districts based upon the information provided and it is subsequently determined that the student does not actually reside in Brimfield, Brookfield, Holland, Sturbridge, or Wales, I/we understand that the student's enrollment in the Tantasqua Regional/Union 61 School Districts will be promptly terminated and I/we will be jointly and severally liable to the Tantasqua Regional/Union 61 School Districts for the student's tuition for the full academic year(s). I/we further certify that I am/we are the parent(s) or legal guardian(s) of the above student. Print parent/guardian full name and relationship Print parent/guardian full name and relationship I/we understand that all applicants must reside in the town of Brimfield, Brookfield, Holland, Sturbridge, or Wales per MGL Ch. 76 Section 5 which states that every person shall have a right to attend the public schools of the town where he/she actually resides, subject to the following section. No school committee is required to enroll a person who does not actually reside in the town unless said enrollment is authorized by law or by the school committee. Any person who violates or assists in the violation of this provision may be required to remit full restitution to the town of the improperly-attended public schools. No person shall be excluded from or discriminated against in admission to a public school of any town, or in obtaining the advantages, privileges and courses of study of such public school on account of race, color, sex, religion, national origin, sexual orientation or homelessness. Amended by st. 1971, c. 622,c.1; st. 1973, c.925, s. 9A, st. 1993, c. 282; st. 2004, c. 352, s. 33. Under penalties of perjury I/We attest that the above information is correct and true. Parent/Guardian Signature Date Parent/Guardian Signature For School Use Only Date Received at School Approved

12 BURGESS ELEMENTARY SCHOOL Sturbridge Massachusetts Dear parent/guardian: Important Please provide a copy of your child s birth certificate for our medical records. It should be the official town record, not the hospital certificate. Thank you. Lisa Meunier School Nurse

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15 IEP (Individual Education Plan) if applicable Please provide us with a copy of your child s IEP/504 from the previous school your child attended.

16 Letter of Discipline Status (from previous school) You must obtain a statement from your child s previous school stating whether or not your child has been suspended or expelled.

17 MASSACHUSETTS SCHOOL HEALTH RECORD Health Care Provider s Examination Name Male Female Date of Birth: Medical History Pertinent Family History Current Health Issues Y N Allergies: Please list: Medications Food Other History of Anaphylaxis to Epi-Pen : Yes No Asthma: Asthma Action Plan Yes No (Please attach) Diabetes: Type I Type II Seizure disorder: Other (Please specify) Current Medications (if relevant to the student's health and safety) Please circle those administered in school; a separate medication order form is needed for each medication administered in school. Physical Examination Date of Examination: Hgt: ( %) Wgt : ( %) BMI: ( %) BP: (Check = Normal / If abnormal, please describe.) General Lungs Extremities Skin Heart Neurologic HEENT Abdomen Other Dental/Oral Genitalia Treatment Plan - Screening: (Pass) (Fail) (Pass) (Fail) (Pass) (Fail) Vision: Right Eye Hearing: Right Ear Postural Screening: Left Eye Left Ear (Scoliosis/Kyphosis/Lordosis) Stereopsis Laboratory Results: Lead Date Other The entire examination was normal: Targeted TB Skin Testing: Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors): Date of PPD: ; Results: mm. Referred for evaluation to: Low risk (no PPD done) This student has the following problems that may impact his/her educational experience: Vision Hearing Speech/Language Fine/Gross Motor Deficit Emotional/Social Behavior Other Comments/Recommendations: Y N This student may participate fully in the school program, including physical education and competitive sports. If no, please list restrictions: Y N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System Certificate or other complete immunization record. Signature of Examiner Circle: MD, DO, NP, PA Date Please print name of Examiner. Group Practice Telephone Address City State Zip Code Please attach additional information as needed for the health and safety of the student. MDPH/TR&U61 07/08/15

18 Tantasqua Regional & Union 61 School District Brimfield, Brookfield, Holland, Sturbridge, & Wales Massachusetts School Health Immunization Record School: Female Year of Graduation: Name: Male Last First Middle DOB / / Place of Birth: Street: City, State, Zip Code: Primary Language Spoken (home): Insurance: ALLERGIES: VACCINE DATE/VACCINE VACCINE DATE/VACCINE TYPE VACCINE Hepatitis B 1 Pneumococcal 1 Pneumococcal 1 Conjugate Polysaccharide 2 (PCV7) 2 (PPV23) 2 DATE/VACCINE TYPE 3 3 Hepatitis A Diptheria, Tetanus, Pertussis (DPT) (DPaT) 1 Rotavirus 1 Human 1 Papillomavirus (HPV) Measles, Mumps, Rubella H1N1 1 6 Varivax Vaccine 1 H1N1 2 Hemophilus influenza Type b 1 Varivax Vaccine 2 Other 2 Meningococcal 1 Chickenpox History MD Verified Date 3 2 PPD 4 Influenza 1 PPD Polio 1 2 TB Risk (Check if Low ) 2 3 TB Risk Low Date: 3 4 Lead Level 4 5 Lead Level Serologic Proof of Immunity Check One Test (if done) Date of Test Positive Negative Measles / / Mumps / / Rubella / / Varicella* / / Hepatitis B / / * Must also check Chickenpox History box. Chickenpox History Check the box if this person has a physiciancertified reliable history of chickenpox. Reliable history may be based on: physician interpretation of parent/guardian description of chickenpox physical diagnosis of chickenpox, or serologic proof of immunity I certify that this immunization information was transferred from the above-named individual s medical records. Doctor or Nurse s Signature: Date:

19 PROOF OF RESIDENCY File: JEC STURBRIDGE SCHOOL COMMITTEE POLICY SCHOOL ADMISSIONS All children of school age who reside in the Town of Sturbridge will be entitled to attend the public school. The town of Sturbridge does not participate in school choice. Advance registration for prospective kindergarten students will take place in the spring. Every student seeking admission to the school for the first time must present a birth certificate or equivalent proof of age acceptable to the principal and proof of vaccination and immunization as required by the state and the school committee. Two forms of documenting proof of residency one from Category A and one from Category B of the parents or guardian will also be required. Examples of these documents are: Category A: 1. Current paid Residential Real Estate Tax Bill (for the home in which you are residing) 2. Purchase and Sale Agreement 3. Rental or Lease Agreement Category B 1. Utility Bill under parent/guardian name 2. Voter Registration 3. Valid Driver s License Proof of residency may be required at any time. All members of the school community are expected to report violations of this policy to a building administrator. Any student moving within the Union 61 member towns after January 1 during their sixth grade year and has provided proof of residency in said town has the option of completing the school year. Transportation will not be provided by the town. Legal References: M.G.L. 15:1G, 76:1; 76:5; 76:15, 76:15A Cross References JHCA, Physical Examination of Students JHCB, Inoculation of Students Adopted: 12/5/96 Amended First Reading Amended Second Reading Amended: Adoption

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