New Berlin Jr/High School 2010-2011 Registration Form
Please read carefully and correct or add information as needed
Last Name: ___________________ First Name:____________________ Middle Name: _____________________ Gender: _______ D.O.B.: _________ SSN: ___________________ Grad Year: __________ Place of Birth : _____________ ( Circle one) American Indian, Asian, Black, Hispanic, Caucasian, Multiracial Guardian/Mailing Information *Stepparents or non-custodial parents must also be listed as emergency contacts
Relationship to Student: _____________________
Home Address: ____________________________
P.O. Box: _________________________________
City, State, Zip:____________________________
Cell Phone: _______________________________ _______________________________________
Guardian’s Email Address: ________________________ Second Family
Guardian Name: _____________________________
Relationship to Student:_______________________ Home Address: ______________________________ Office Use
P.O. Box: ______________
City, State, Zip: ______________________________
Cell Phone: _________________________________ Work Phone: _________________________________ Work Location: ______________________________ Second Family’s Email Address: _________________________________________ School Reach Telephone#_______________________________ Emergency Contact Information
Please list 2 Relatives/Neighbors who WILL CARE FOR STUDENTS IF PARENTS/GUARDIAN CANNOT BE REACHED.
Students will be released to these RELATIVES/NEIGHBORS ONLY.
Emergency Contacts:Must be updated yearly Contact Name: Contact Phone#: Relationship: ______________________________________________________________ ________________________________ __________________________ ______________________________________________________________ ________________________________ __________________________ ______________________________________________________________ ________________________________ __________________________ ______________________________________________________________ ________________________________ __________________________ [ ] I _________________________________________ authorize Community Unit School District # 16 to release Parent/Guardian (Please Print) Medical information regarding _______________________________________ to school personnel responsible for Child’s Name (Please Print) supervising my child at school. ___________________________________________________ Parent/Guardian signature Date Please list all student’s pertinent health problems and/or allergies: _______________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ Doctor’s Name:__________________ Doctor’s Phone: _______________________ Hospital: _______________ Hospital’s Phone #: _____________________
[ ] I give my child _________________________ permission to take acetaminophen (generic Tylenol) at school if needed for complaints of headache or pain. (Generic Tylenol 325 mg. is kept in the nurse’s office in a locked cabinet). The nurse will monitor safety of administration. The nurse/administrator or a teacher may administer the medication. [ ] I do not want my child ____________________________ to take acetaminophen(generic Tylenol) at school. ____________________________________ _____________________________ Parent/Guardian Signature Date
[ ] My student’s name and picture/s may be included in the school yearbook [ ] My student’s name and picture/s MAY NOT be included in the school yearbook. [ ] My student’s name, grade, award recognition, activity, and athletic information may be included in press releases and school related websites. EX: The New Berlin BEE, school website, etc. [ ] My student’s name, grade, award recognition, activity, and athletic information MAY NOT be included in press releases and school related websites. Community Unit School District #16 follows the practice of forwarding student records at the request of a District to which the student is transferring. ____________________________________ _________________________
Home Language Survey
The state requires the district to collect a Home Language Survey for every new student. This information is used to count the students whose families speak a language other that English at home. It also helps to identify the students that need to be assessed for English language proficiency. Please answer the questions below and return this survey to your child's school. Student's Name:_________________________________
1. Does anyone in your home speak a language other than English?
What language? ___________________________
2. Does your child speak a language other than English?
What language? ____________________________
No___________ If the answer to either question is yes, the law requires the school to assess your child's English language proficiency. ___________________________________ __________________ Parent
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