AGAWAM PUBLIC SCHOOL ENROLLMENT PACKET GRADES K - 12
STUDENT REGISTRATION CHECKLIST 3 Forms of proof of residency (see proof of residence requirements) Parent/Guardian Photo ID Birth Certificate Proof of Physical Examination done within the year (or appt. card for scheduled exam) Most recent immunization record (see medical requirements) Most recent school records Withdrawal form Academic Transcript / Report Card Discipline Records / Reports Special Education documentation (most recent copy of I.E.P. if applicable) Court / Legal guardianship / custody documents. Proof that adult is seeking guardianship (copy of petition form for guardianship: stamped and dated Court Document with Docket Number indicated) Completed enrollment information
PROOF OF RESIDENCY REQUIREMENTS (Signed notarized affidavit expires 1 year No Exceptions) School Committee Policy JHD, Exclusions and Exemptions from School Attendance, as well as Massachusetts General Law, Chapter 76, Section 5, before any student is assigned to attend Agawam Public Schools, the student s parent or legal guardian must prove legal residence in the Town of Agawam. Families whose primary residence is outside of Agawam are not eligible to attend Agawam Public Schools. Effective November 15, 2005, all applicants must submit at least three proofs of residency. Documents must be preprinted with the name and address of the student s parent or legal guardian and must be presented at the time of registration. These documents also will be required for any change of address. All applicants must submit at least one document From each of the following columns: Column A Column B Column C Copy of Deed AND/OR record of most recent mortgage payment Copy of Lease AND record of most recent rent payment Notarized Legal affidavit from landlord affirming tenancy 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 WIC/Mass Health Valid driver s license Current vehicle registration Valid Massachusetts photo identification 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 approved government agency Payroll stub Bank or credit card statement Legal guardianship requires additional documentation from a court or agency. If living with friends or relatives, the friend or relative will need to provide (3) forms of their proof of residence in addition to your (3) forms of proof of residence If you are unable to provide any one document from each column you must contact the central office to set up a meeting with our residency coordinator, John Nettis, 413-523-0481. Please note: In Massachusetts, entitlement to public education is based on residency. Per the above referenced section, Every person shall have a right to attend the public schools of the town where he actually resides; subject to the following section. Courts have consistently focused the residence inquiry on the actual, day-to-day residence of the student, Board of Education v Amesbury, 16 Mass App. Ct. 508,452 N.E.2d 302 (1998). It is the child s residence which determines the assignment of responsibility for educational matters. Walker Home for Children, Inc. v Franklin, 416 Mass 291, 621 N.E. Please report residency fraud! Call anonymously to the Student Assignment Office.
CERTIFICATION OF STUDENT RESIDENCY This certification is required if the student is living in the home of an Agawam adult who is not his/her parent or guardian. This form must be completed even if the parent and/or guardian is living with the student in this Agawam residence. It will expire at the end of each school year. Please be aware that M.G.L. c. 76, 5 allows the School Committee to obtain the full cost of any student s education from any adult who enrolled a student in the Agawam Public Schools, knowing that the student was not a resident. NAME OF SCHOOL STUDENT S FULL NAME RESIDENCE DATE OF BIRTH I understand that the student whose name appears above must actually be residing in the Town of Agawam and has an intention to remain there in order to attend the Agawam Public Schools. As the adult with whom this student is now residing at the address shown above, I understand that the activity listed below indicates residency and that the above-named student does engage in this activity to the extent indicated below and therefore is a resident of the Town of Agawam. I also understand that I must notify school authorities of any changes of address. Please complete the following for students in all grades: The student returns to the address listed in this certification at the end of each school day and spends the evening/night there. Yes No Signed under the pains and penalties of perjury this day of, 20 Month Year Printed name of adult responsible for student Signature On this day of, 20, before me, the undersigned Notary Public, personally appeared (name of document Signer), proved to me through satisfactory evidence of identification, which were, to be the person whose name is signed on the preceding or attached document in my presence. Official signature and seal of notary Notary Commission expiration date
Residency ENROLLMENT FORM Entry Date STUDENT INFORMATION NAME: CLASS OF: SASID: LAST FIRST FULL MIDDLE NAME ADDRESS: STREET CITY STATE ZIP HOME TELEPHONE: GRADE ENTERING: SEX: DOB: / / PLACE OF BIRTH: CITY STATE COUNTRY STUDENT IS PRESENTLY LIVING WITH: (check all that apply): Biological Parents Biological Mother Biological Father Step-Mother Step-Father Foster Parents Other (Explain): SCHOOL LAST ATTENDED: GRADE COMPLETED: ADDRESS OF SCHOOL: STREET CITY/TOWN STATE ZIP DID YOU EVER ATTEND SCHOOL IN MASSACHUSETTS BEFORE? IN AGAWAM? WHICH SCHOOL? STUDENT RANKS AMONG LIVING CHILDREN HOW MANY YEARS HAS YOUR CHILD BEEN IN THE U.S.? PREVIOUS COUNTRY? SPECIAL NEEDS: YES NO IF YES, EXPLAIN OTHER IMPORTANT INFORMATION: PEDIATRICIAN S NAME: PHONE NUMBER: WILL YOU ALLOW SCHOOL TO CONTACT DOCTOR? YES NO LEGAL PARENT/GUARDIAN INFORMATION PARENT/GUARDIAN #1: LIVING? OCCUPATION: LEGAL HOME ADDRESS (IF DIFFERENT): TELEPHONE: EMPLOYER: TELEPHONE: EMAIL: CELL PHONE: PARENT/GUARDIAN #2: LIVING? OCCUPATION: LEGAL HOME ADDRESS (IF DIFFERENT): TELEPHONE: EMPLOYER: TELEPHONE: EMAIL: CELL PHONE: SIGNED DATE
STUDENT EMERGENCY INFORMATION Student Name: EMERGENCY CONTACTS OTHER THAN LEGAL PARENTS/GUARDIANS ONLY PROVIDE PEOPLE WHO CAN BE REACHED DURING SCHOOL HOURS Emergency Contact #1 Relationship to student City/State Phone #1 Phone #2 Emergency Contact #2 Relationship to student City/State Phone #1 Phone #2 Emergency Contact #3 Relationship to student City/State Phone #1 Phone #2 Emergency Contact #4 Relationship to student City/State Phone #1 Phone #2 Emergency Contact #5 Relationship to student City/State Phone #1 Phone #2 Emergency Contact #6 Relationship to student City/State Phone #1 Phone #2
Student Name: ADDITIONAL EDUCATION INFORMATION Does this student have any special educational needs? Yes No If yes, please explain Does this student have an IEP (Individual Educational Plan) on file? Yes No Does this student have a 504 Accommodation Plan? Yes No Does this child require special transportation? Yes No Does this student have ELL/ESOL Services? Yes No Does this student have DCAP Plan? Yes No HOME LANGUAGE SURVEY Does this student speak English? Yes No If no, what is student s first native language? What language do you speak most often at home? What language does your child most often use when speaking to you at home? Does this student require an English Language Learner program? Yes No
STUDENT S EDUCATIONAL HISTORY STUDENT NAME: NAME OF SCHOOL GRADE LEVEL CITY/STATE DATES ATTENDED to to to to to to to STUDENT S STATE COLLECTION DATA RACE (You may select one or more races) WHITE a person having origins in any of the original peoples of Europe, the Middle East or North America BLACK or AFRICAN AMERICAN a person having origins in any of the black racial groups of Africa. AMERICAN INDIAN OR ALSAKA NATIVE a person having origins in any of the original people of North and South America (including Central America), and who maintain 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, Philippine Islands, Thailand and Vietnam. NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER a person having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific Islands. HISPANIC or LATHINO a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Other
RECORD RELEASE FORM TO: Name of Street Address: City / Town: State: Zip Code: Telephone Number: Fax Number: ******************************************************************************************** Students Full Name: DOB GRADE I hereby authorize the following information be released to Agawam Public Schools for the student at the institution named above. Academic Records Health & Immunization Records Transcripts of Grades/Recent Report Card Test Records (i.e. MCAS) Discipline Records (if no record exists, please indicate as such) Individual Education Plans (IEP) and Reports (if applicable) SASID Number 504 or DCAP Plans (if applicable) Please forward the records to the school circled below. Agawam High School Attn: Guidance Dept. 760 Cooper Street Agawam, MA 01001 Fax # 413-789-0341 Agawam Junior High Attn: Guidance Dept. 1305 Springfield Street Feeding Hills, MA 01030 Fax # 413-786-4240 Roberta Doering Middle Attn: Guidance Dept. 68 Main Street Agawam, MA 01001 Fax # 413-789-7337 Benjamin Phelps Elementary 689 Main Street Agawam, MA 01001 Fax # 413-786-0497 Robinson Park Elementary Clifford Granger Elementary James Clark Elementary 65 Begley Street Agawam, MA 01001 Fax # 413-786-9793 31 S. Westfield Street Feeding Hills, MA 01030 Fax # 413-821-0595 65 Oxford Street Agawam, MA 01001 Fax # 821-0594 Signed: Date: Signature of Parent/Guardian
EARLY CHILDHOOD EDUCATION EXPERIENCE SURVEY Please check next to the option that best describes your child s preschool experience in the school year prior to entering Kindergarten. Select one option only, and indicate hours where applicable. Thank you! Name of child: Date of Birth: My child did not have any formal early childhood program experience My child did not have formal early childhood program experience but participated in Coordinated Family and Community Engagement (CFCE) services. My child did not have formal early childhood program experience but participated in Parent Child Home Program (PCHP) services. My child did not have formal early childhood program experience but participated in BOTH Coordinated Family and Community Engagement (CFCE) AND Parent Child Home Program (PCHP) services. My child attended a Licensed Family Child Care Provider (indicate hours below) for less than 20 hours per week for 20+ hours per week My child attended a Center Based Program (indicate hours below) for less than 20 hours per week for 20+ hours per week My child attended BOTH a Licensed Family Child Care Provider AND a Center Based Program (indicate hours below) for less than 20 hours per week for 20+ hours per week Definitions: Coordinated Family and Community Engagement (CFCE) Services: locally based programs serving families with children birth through school age (e.g. parent/child playgroups, parent-child activities). Parent Child Home Program (PCHP): home visiting model program funded through the Department of Early Education and Care. Licensed Family Childcare: refers to EEC licensed child care in a group setting in a home. It may include care in the home of a family member, if the provider is both a relative and an EEC licensed child care provider providing care to children from multiple families. Center-Based Care: refers to care for children in a group setting, including public and private preschools, Head Start, day care centers, and integrated public preschools.
A physical examination form completed by the child s Health Care provider is required of all students entering Agawam Schools. The physical examination should be recent (done within the past year). SCHOOL IMMUNIZATION LAW CHAPTER 76, SECTION 15 OF THE GENERAL LAWS OF MASSACHUSETTS Massachusetts State Law states that no child shall be admitted to school except upon presentation of a physician or a clinic s certificate stating that the child has been immunized against the following: DIPHTHERIA, PERTUSSIS, TETANUS (DPT, DTaP) MEASLES, MUMPS, RUBELLA (MMR) POLIO HEPATITIS B VARICELLA TB TEST 5 Doses* 2 Doses 4 Doses** 3 Doses 2 Doses*** Recommended if new from outside USA TDAP Is required for entry to 7 12 * 5 doses of DTaP/DYP are required for school entry unless the fourth dose was given on or after the 4 th birthday. ** 4 th Polio dose required if 3 rd dose given before the 4 th birthday or if sequential OPV/IPV used. *** Or physician certified disease to prevent chicken pox
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 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): TB Test Type: TST IGRA Date: Result: Positive Negative Indeterminate/Borderline Referred for evaluation to: Date: Low risk (no TB test 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 09/07/18
Town of Agawam Health Department/School Nurse Division Student Health History Agawam School System Please Print Students Name: Last First: Grade: DOB: CONDITION: Dates Dates ADD/ADHD Yes No Hearing Loss Yes No Asthma Yes No Impaired Vision Yes No Autism Yes No Cystic Fibrosis Yes No Diabetes (sugar) Yes No Kidney Trouble Yes No Seizures Yes No Headaches Yes No Convulsions Yes No Ear Infections Frequent Few No Scoliosis Yes No Tubes in ears Now Past No Cerebral palsy Yes No Muscular Dystrophy Yes No Other Chronic Diseases: Please Specify: ALLERGIES: Does your child have any life threatening allergies, which would require an Epipen? (Medication, insects, bees, foods, etc.) Yes No Please explain: **Parent must provide the Epipen and signed doctor s orders annually. Does your child have any non life threatening allergies? (Foods, animals, seasonal, etc.) YES NO Please explain: MEDICATION: Does your child take any pills, medicines or treatments on a regular or part-time basis? YES NO Please list: Does your child use any of these aids? Dental Plate / Appliance Yes No Crutches Yes No Gastrostomy Tube Yes No Braces for Arm or Leg Yes No Contact Lens Yes No Walker Yes No Eyeglasses Yes No Wheelchair Yes No Hearing Air Yes No Other (Please specify) Are there other health problems not mentioned? Yes No If yes, please explain or give medical diagnosis and doctor s name Can your child participate in all school activities? Yes No If no, please explain Vision, hearing, height, weight and Postural Screenings (grades 5-9) will be one annually or as mandated by the Department of Public Health. Please notify the School Nurse if you choose to opt out. When applicable, this personal health information will be shared with appropriate school staff to better serve the medical and educational needs of your child. I understand this authorization is voluntary. Date Parent s Signature Phone
TOWN OF AGAWAM HEALTH DEPARTMENT/SCHOOL NURSE DIVISION K 4 DENTAL EXAMINATION REQUEST Date: Re: Student s Name Grade: Tel: ************************************************************************************* Has your child had a dental examination by your family dentist within the last six months? If not will you arrange for such an examination as soon as possible? In either case, please have the dentist fill in and sign below, then return this sheet to the school nurse. This is to certify that I examined and found the condition check below: No dental defects. Dental defects which were present have been completely cared for. Treatment has been started. Treatment is needed but no provision is made for it. Date: Signature of Dentist: It is not possible to take my child to the family dentist for an examination. Parent or Guardian