STONEHAM PUBLIC SCHOOLS

149 FRANKLIN STREET

STONEHAM, MASSACHUSETTS 02180
(781) 279-3800

Welcome to
Stoneham Public Schools
K-12 Registration
School Grade Telephone Fax
Colonial Park Elementary School K-4 781-279-3890 781-279-3892
Robin Hood Elementary School K-4 781-279-3870 781-438-8697
South Elementary School K-4 781-279-3880 781-279-2104
Stoneham Central Middle School 5-8 781-279-3840 781-279-3843
Stoneham High School 9 - 12 781-279-3810 781-279-2070

We look forward to your child entering Stoneham Public Schools. Please take the time to read carefully
through the following information – it should answer many of your important questions. Should you
have any further questions, please do not hesitate to call your school office.

REGISTRATION DOCUMENTS: It is important that all documents, especially proof of residency,

birth certificate and a recent physical exam and updated immunization information, are on file in the
school prior to your child’s entrance in September. IMPORTANT: Only completed registration
packets will be accepted.

IMPORTANT: What You Will Need:

1. Registration packet (attached)
2. A copy of your child’s recent physical exam and immunizations.
3. Birth Certificate
4. Three Proofs of residence must be submitted (See attached Policy 9-17.2)).
5. Please note: Proof of custody may be required if the person registering a student is not the
person whose name is on the child’s birth certificate.
6. Release of School Records from prior school, if any.

GRADES K-12 APPLICATIONS SHOULD BE RETURNED TO YOUR DISTRICT

SCHOOL. DURING SUMMER MONTHS, ELEMENTARY REGISTRATIONS
SHOULD BE RETURNED TO:

Office of the Superintendent

Stoneham Public Schools
149 Franklin Street
Stoneham, MA 02180
781-279-3802

The Stoneham Public Schools do not discriminate on the basis of race,

color, sex, religion, national origin, sexual orientation or disability.
Jan. 2021
 INCOMING KINDERGARTEN STUDENTS ONLY

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.
 OFFICE USE ONLY
STONEHAM PUBLIC SCHOOLS SCHOOL:

Student Registration Information Birth Certificate

Immunization/PE Records
(Please type or print clearly)
Proof of Residency

Student Information
Legal Last Name Gender
□ Male □ Female □ Non-Binary
Legal First Name Home Phone

Full Middle Name

Student’s Residential Address (Street address required) Student’s Mailing Address (if different from residence; P.O. Box)

Date of Birth (MM/DD/YYYY) City of Birth State of Birth Country of Birth

School Entering Grade Level Year of Graduation

Student Lives With? □ Both Parents □ Mother □ Father □ Legal Guardian □ State Ward □ Foster Home
□ Other – Please Specify:

Parent/Guardian Information
Parent/Guardian 1 Legal First Name Middle Name
(Must match information provided on the
Parent/Guardian Information Form)
Legal Last Name Legal Status Relationship

Parent/Guardian 2 Legal First Name Middle Name

(Must match information provided on the
Parent/Guardian Information Form)
Legal Last Name Legal Status Relationship

Legal Status = Custodial Parent, Non-Custodial Parent or Guardian; Relationship = Mother, Father, Grandparent, etc.

Emergency Contact Information

Local Emergency Contact #1 Name Phone
(a neighbor, close friend, or relative)

Address Relationship

Local Emergency Contact #2 Name Phone

(a neighbor, close friend, or relative)

Address Relationship
Other Information
Has the student previously attended school in Stoneham? □ Yes (Check if yes) Grade Level(s):

Has student previously attended another school? □ Yes (Check if yes)

Previous School and Address □ Public
□ Private / Parochial

Child’s Primary Language: Primary Language Spoken at Home:

Does your child receive special services? □ Yes (Check if yes) Explain:

Siblings
Name Age School Attending Grade Level Lives with student?

1. □ Yes □ No
2. □ Yes □ No
3. □ Yes □ No
4. □ Yes □ No
5. □ Yes □ No

Race & Ethnicity: Every school district in Massachusetts is required to report to the Department of Elementary and
Secondary Education student data by race and ethnicity categories that are set by the federal government.

Is the student’s Ethnicity Hispanic or Latino? (Check one)

□ Yes A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless
of race. The term, “Spanish origin,” can be used in addition to Hispanic or Latino
□ No Not Hispanic or Latino

Student’s Race (Check one or more)

□ American Indian or Alaskan Native – A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation of community Attachment.
□ Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinents
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 s 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.

Additional Information
Please feel free to provide any additional information you would like to share:

Signature of
Date
Parent/Guardian

Print Name Relationship

Please complete the Parent/Guardian Information form. Only one form is required per
family. Supply with first student registered.
 Stoneham Public Schools
Parent/Guardian Information
Student Name Age School Attending Grade Level
1.
2.
3.
4.
5.
Parent Current Military Status (If Applicable): Active Duty Died on Active Duty
Discharged/Retired (within one year)

Parent/Guardian 1 (Primary Contact)

Legal First Name: Middle Name:

Legal Last Name:

Gender □ Male □ Female Guardian Email

Employer

Relationship to Student** Legal Status**

Can Dismiss Student from School? □ Yes □ No Can Pick-up Student from School? □ Yes □ No
Lives with student? □ Yes □ No Receives Mail □ Yes □ No (Default will be Guardian #1)
Same as student?
Address
□ Yes □ No
Phone – Rank 1* Phone – Rank 2*
Phone – Rank 3* Phone – Rank 4*
*Stoneham Public Schools uses a school-to-parent communication system to send emergency, periodic and personalized messages by telephone. Please
provide the numbers you want included in our system. The Rank 1 number will be used to contact the custodian parent/legal guardian for weather alerts,
attendance calls and general announcements. ALL CUSTODIAL PARENT/GUARDIAN NUMBERS WILL RECEIVE EMERGENCY CALLS.
Parent/Guardian 2
Legal First Name: Middle Name:

Legal Last Name:

Gender □ Male □ Female Guardian Email

Employer

Relationship to Student** Legal Status**

Can Dismiss Student from School? □ Yes □ No Can Pick-up Student from School? □ Yes □ No
Lives with student? □ Yes □ No Receives Mail □ Yes □ No (Default will be Guardian #1)
Same as student?
Address
□ Yes □ No
Phone – Rank 1* Phone – Rank 2*
Phone – Rank 3* Phone – Rank 4*

Reference Key**
Relationship Choose from: Mother, Father, Parent, Step Mother, Step Father, Step Parent, Foster Parent, Grandparent, Relative, Sibling, Neighbor, Friend, Other
Legal Status Indicate “Custodial Parent” or “Non-Custodial Parent”; “Legal Guardian”, “State Ward” or “Self” (18+ Yrs) (Default = Custodial
Parent)
 STONEHAM PUBLIC SCHOOLS
STUDENT MEDICAL HISTORY
This information will be placed on the Massachusetts School Health Record and will follow your child throughout their school
years. It will be kept confidential and stored in a locked file cabinet. If any of this information changes remember to notify
your child’s school nurse.

If you need to speak privately with your child’s school nurse, please call to schedule an appointment.

SECTION 1 - STUDENT INFORMATION

First Name: Middle Name:
Last Name: DOB:
Male Female Place of Birth (City/State):
Street
Address: (street/apt #) (town & state) (zip)

Mailing
_
Address: (P.O. Box #) (town & state) (zip)

SECTION 2 - PARENT INFORMATION

Child lives with Both Parents Mother Father Guardian

Parent #1 Full Name: Relationship:

Phone (h): (w): (c):

Parent #1
Address: (street/apt #) (town & state) (zip)

Parent #1 Employer:
Parent #2 Full Name: _ Relationship:
Phone (h): (w): (c):

Parent #2
Address: (street/apt #) (town & state) (zip)

Parent #2 Employer:
Alternate Emergency Contact: Phone:
SECTION 3 - HEALTH CARE PROVIDER INFORMATION
Does your child have medical insurance? Yes No
Does your child have dental insurance? Yes No
Doctor’s Name: _ Phone:
Doctor’s Address:
Dentist’s Name: Phone:
Dentist’s Address: _

Please return form to the nurse at your child’s school.

 STONEHAM PUBLIC SCHOOLS
STUDENT MEDICAL HISTORY
SECTION 4 - SIBLING INFORMATION
Please provide the following information about your child’s siblings (use additional paper if necessary):
Name Grade & Building Significant Medical History

SECTION 5 - MEDICAL INFORMATION

Please explain any medical problems your child might have (or had):

Please list any medication your child takes, the dose, and when it is taken (including
prescription, over-the-counter, herbal, vitamins,
etc.): _

Please list any allergies your child has (please be specific and explain how each allergy is managed):

SECTION 6 - EDUCATIONAL INFORMATION

Is your child currently on an IEP or 504 Plan?  No  Yes, please explain:

SECTION 7 – STEP PARENT INFORMATION ( Check if Not Applicable)

Child’s step father’s full name:
Address: Phone:
Child’s step mother’s full name:
Address: Phone:
If parents are separated, please list the parent your child does not live with:

Address: Phone:
SECTION 8 – PARENT/GUARDIAN SIGNATURE

Signature: Date:

Printed Name: Relationship:

Stoneham High School Stoneham Central Middle School Colonial Park Elementary
Attn: School Nurse Attn: School Nurse Attn: School Nurse
149 Franklin Street 101 Central Street 30 Avalon Road
Stoneham, MA 02180 Stoneham, MA 02180 Stoneham, MA 02180
Tel. 781-279-3810 Ext. 317 Tel. 781-279-3840 Tel. 781-279-3890
Robin Hood Elementary South Elementary
Attn: School Nurse Attn: School Nurse
70 Oak Street 11 Summer Street
Stoneham, MA 02180 Stoneham, MA 02180
Tel. 781-279-3890 Tel. 781-279-3890
Please return form to the nurse at your child’s school.
 STONEHAM PUBLIC SCHOOLS
149 Franklin Street, Stoneham, MA 02180 781-279-3802 www.stonehamschools.org

CONSENT FOR RELEASE OF SCHOOL RECORDS

The “Family Education Rights and Privacy Act of 1974” requires that a student’s parents or legal guardians be
aware that their child’s records are being released to another school district.

I hereby authorize the release of the school records for the following:

Student Name: D.O.B. Current Grade:

REQUEST RECORDS FROM:

Previous School Name:
Address:

Telephone: Fax:

Include the following information:

o Subjects, marks and credits earned
o Grades to date of withdrawal
o Standardized test results
o Attendance records
o Health records
o Educational plan and Special Education records (IEP, Behavior Plan, 504 Plan, ELL)
o Discipline records
o Other:

RECORDS SHOULD BE SENT TO: (Check box for appropriate receiving school)

Stoneham High School Stoneham Central Middle School

149 Franklin Street 101 Central Street
Stoneham, MA 02180
Stoneham, MA 02180

Colonial Park Elementary Robin Hood Elementary

30 Avalon Road 70 Oak Street
Stoneham, MA 02180 Stoneham, MA 02180

South Elementary Office of the Superintendent

11 Summer Street Stoneham Public Schools
Stoneham, MA 02180 149 Franklin Street
Stoneham, MA 02180
 Home Language Survey
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
/ /20 ______
Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade

Questions for Parents/Guardians

What is the primary language used in the home, regardless of the Which language(s) are spoken with your child?
language spoken by the student? (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 languages does your child use? (circle one)

How many years has the student been in U.S. Schools? (not including
pre-kindergarten) seldom / sometimes / often / always

seldom / sometimes / often / always

Will you require written information from school in your native Will you require an interpreter/translator at Parent-Teacher meetings?
language? Y N Y N

If yes, what language? ________________________________ If yes, what language? ________________________________

Parent/Guardian Signature:
/ /20
X Today’s Date: (mm/dd/yyyy)
 9-17.2

STONEHAM REGISTRATION AND RESIDENCY POLICY

Registration
In order to register and attend the Stoneham Public Schools, a student must actually reside in the Town of
Stoneham with a parent/legal guardian. “Residency” is defined as the place where a person has his/her
permanent home, i.e., “the place where a person dwells and which is the center of his domestic, social and civil
life.”1For minor children, the legal residency is presumed to be the legal residence of the parent(s) or legal
guardian(s) who has physical custody of the minor child.

Students who are visiting Stoneham are not eligible to attend the Stoneham Public Schools.

Please read below and provide documents as indicated:

1. Proof of Age (Original Birth Certificate or Passport)

2. Proof of Immunization (Medical/Health Record)
3. SPS Registration Form(s)
4. Proof of Residency/Occupancy (see Proof of Residency/Occupancy Documents Required for Registration
– page 2)
5. Joint Physical Custody
In cases of separation or divorce, physical custody agreements must be presented to the district school.
Documentation must establish the student’s residence is in Stoneham.

Residency Requirements
The Stoneham Public Schools reserves the right to request proof of residency/occupancy when students are
initially enrolled. The types of documents requested as proof of residency/occupancy are listed on page 2.
Stoneham Public Schools also reserves the right to verify residency at the time of enrollment and during the
academic school year. Since family situations can change, the Stoneham Public Schools reserves the right to
request additional, updated information when warranted.

The Superintendent or his/her designee may initiate an investigation in conjunction with the School Resource
Officer, including, but not limited to, a home visit to verify residency. If a student is found not to be actually
residing in the Town of Stoneham, the student will need to enroll in the school district of the city/town where
he/she actually resides. Factors that may trigger an investigation include, but are not limited to, the following:
changes in residency not reported immediately to the school where the student is enrolled; mail returned to
the school; incomplete or contradictory proofs of residency; or anonymous calls reporting suspected residency
violations.

Families found to be in violation of these requirements will face strict penalties, including, but not limited to,
immediate unenrollment from school; per diem charges for the education and related services accessed as a
non-resident which are based on the per pupil cost to the district; and possible legal action.

The following documents will be required as a proof of a physical address in Stoneham when new
students are registered. P. O. Boxes will not be accepted with the exception of documented court related
reasons.

1 1
See Teel v. Hamilton-Wenham Regional School District, 13 Mass. App. Ct. 345, 348 (1982)
 9-17.2

PROOF OF RESIDENCY/OCCUPANCY DOCUMENTS REQUIRED FOR

REGISTRATION IN THE STONEHAM PUBLIC SCHOOLS

Below please find the required proof of residency and occupancy documents necessary for
registration of all students. For families who do not have acceptable proof of residency and proof of
occupancy, Residency Certification Forms are required (see below).
Established Stoneham Residents New Residents of Stoneham
Provide one (1) document from Proof of Residency Provide one (1) document from Proof of Residency
and two (2) documents from Proof of Occupancy. and two (2) documents from Proof of Occupancy.
Documents must be originals – no photocopies. Documents must be originals – no photocopies.
Provide one (1) from this list.

Current Mortgage Statement Executed Purchase and Sale with a

(Dated within 30 days) Closing Date
Original, Current Lease* signed by Original, Current Lease* signed by
property owner/management company property owner/management company
and tenant. Must include names of all and tenant. Must include names of all
occupants. occupants.
Property Deed-evidence of mortgage Property Deed-evidence of mortgage
payoff must accompany this document. payoff must accompany this document.
Current Electric Bill
Electric Bill
Provide two (2) from this list.
Provide two (2) from this list.

(Dated within 30 days)

( Submitted within 30 days of registration )
Current Gas Bill Gas Bill
(Dated within 30 days) (Submitted within 30 days of registration )

Current Cable/Internet Provider Bill Cable/Internet Provider Bill

(Dated within 30 days) (Submitted within 30 days ofregistration )

Current Home Telephone Bill Home Telephone Bill

(Dated within 30 days) ( Submitted within 30 days of registration)

Car Registration, Car Insurance and

Excise Tax Bill (All 3 REQUIRED)
Required for established/new residents who do not have acceptable documentation of
both Proof of Residency and Proof of Occupancy as detailed above & also for the
following residency categories:
• Tenant-At-Will
RESIDENCY CERTIFICATION • Rental of Rooms in a Stoneham Residence
FORMS • Living with Family/Friends
• Live-in Employment e.g., Nanny, Caretaker, etc.
• Student Over Age 18 Living with Family/Friends
A HOME VISIT WILL BE CONDUCTED AT AN UNSCHEDULED DATE/TIME.

*Original, current lease must accompany all addendums for extending lease Terms.
*Notarized letters from property owners will not be accepted in lieu of a lease.
 9-17.2

Source M.G.L. Chapter 76

February 7, 2019
First Reading
Second Reading March 7, 2019
Adopted March 7, 2019
9-16
Policy Cross Reference
9-17

Related Resources SPS Registration Packet

 Parent(s)/Guardian(s) Residency Certification Requirements and Forms
These forms are required for established/new residents who do not have acceptable
documentation of both Proof of Residency and Proof of Occupancy and for the following
residency categories:
• Tenant-At-Will
• Living with Family/Friends
• Rental of a Room in a Stoneham Residence
• Live-in Employment e.g., Nanny, Caretaker, etc.

A HOME VISIT WILL BE CONDUCTED AT AN UNSCHEDULED DATE/TIME.

In order to attend the Stoneham Public Schools, a student must actually reside in the Town of
Stoneham. The residence of a minor child is presumed to be the legal, primary residence of the
parent(s) or guardian(s) who have physical custody of the child.

In determining residency, Stoneham Public Schools reserves the right to request a variety of
documentation and to conduct an investigation into where a student actually resides. Those
families who cannot provide requested proof of residency will be referred for a residency check
by the Stoneham Police Department, School Resource Officer. Because residency can, and does,
change for students and their families during the course of the academic year, we may continue
to verify residency after the commencement of classes and we may act upon anonymous tips
received to conduct a residency verification investigation. It is also the responsibility of
parent(s)/guardian(s) to notify school personnel immediately if a change in residency occurs.
In addition to parent/guardian information, we also require information from the owner of the
property and the resident(s) in shared tenancy where a family currently resides.

Families found to be in violation of the residency guidelines will face strict penalties, including,
but not limited to, immediate unenrollment from school; per diem fines for the education and
related services accessed as a non-resident which are based on the per pupil cost to the district;
and possible legal action.

Directions:
1. Parent/Guardian Form – the Parent(s)/Guardian(s) must complete all information and have the
form notarized.
2. Shared Tenancy Form – If the family is residing with a tenant and not the property owner, the
person whose name appears on the lease agreement must complete all information and have the
form notarized.
3. Property Owner Pre‐registration Certification Form – The owner of the property must complete
all information and have the form notarized.
4. Bring the original documents, completed and notarized, to the school office where student(s)
is/are to be registered or to the Stoneham Public Schools Superintendent’s Office, 149 Franklin St.
Stoneham, MA (office inside SHS).

SPS Rev. 2019

Parent(s)/Guardian(s) Residency Certification
 Parent(s)/Guardian(s) Residency Certification Form

Parent(s)/Guardian(s) Information
Name Relationship to Student
Current Address
Expected Dates of Residency at Current Address Home Phone
Cell Phone Email Address
Do you pay utility bills (gas, electric, cable/internet) at this address?  Yes  No
If yes, please provide two current utility bills dated within thirty (30) days.
Previous Address Country

Employer Work Phone

Do you own a motor vehicle?  Yes  No
If yes, is the motor vehicle registered in the Town of Stoneham?  Yes  No
If no, please explain

I have legal custody of the following children who will reside with me at the above address:
Name Date of Birth
Previous School
Grade Level Completed Date of Withdrawal

Name Date of Birth

Previous School
Grade Level Date of Withdrawal
Completed

Name Date of Birth

Previous School
Grade Level Date of Withdrawal
Completed

Name Date of Birth

Previous School
Grade Level Date of Withdrawal
Completed

1. The parent(s)/guardian(s) and student(s) keep(s) their personal possessions at the address
listed in this certification.
Yes  No If No, please explain

2. The parent(s)/guardian(s) and student(s) return(s) to the address listed in this certification at
the end of each school day and spend(s) the evening/night.
Yes  No If No, please explain

SPS Rev. 2019

Parent(s)/Guardian(s) Residency Certification
3. The parent(s)/guardian(s) and student(s) receive(s) his/her mail at the address listed in this
certification.
Yes  No If No, please explain

4. The parent(s)/guardian(s) and student(s) stay(s) at the address listed in this certification
over weekends, holidays, and vacation periods.
Yes  No If No, please explain

For Students in Grades 9 - 12

5. Does the student own a motor vehicle?

 Yes  No
6. If Yes, is the motor vehicle registered in the City of Stoneham?
 Yes  No If no, please explain

 I have read and understand the registration and residency requirements for school entrance
and the submission of Registration Certification Forms. I am aware that a home visit will be
conducted at an unscheduled time. It is my obligation to inform my child’s school if there is a
change in the residency of my family or guardianship of my child.

I swear under pains and penalties of perjury that the answers above are true and accurate.

Signature of Parent/Guardian Date

COMMONWEALTH OF MASSACHUSETTS, MIDDLESEX, SS.

Commonwealth of Massachusetts County of

On this _____ day of ,20

(___________________________________________), personally appeared before me, the undersigned

notary public, and proved through satisfactory evidence of identification, which were ___________________,
______________________________________________________________________________________
to be the person whose name is signed on the preceding or attached document, and acknowledged to me
that he/she signed it voluntarily for its stated purpose.

Notary Public My Commission Expires

(Please print or stamp name) Notary Seal

SPS Rev. 2019
Parent(s)/Guardian(s) Residency Certification
 Shared Tenancy Residency Certification Form

*In addition to the information below, please provide a copy of your lease signed by yourself and
property owner/management company and two current utility bills dated within 30 days.
Tenant Information
Name Relationship to Family
Address
Home Phone Cell Phone Email Address

I am the tenant living at ,Stoneham, MA and acknowledge

that the following persons will be residing with me at the above address and the minor children will be
registering for school in Stoneham:
Name of Parent(s)/Guardian(s)_________________________________________________________

Home Phone Cell Phone Email Address

Please list all minor children living with the Parent(s)/Guardian(s) listed above.
Name Date of Birth
Name Date of Birth
Name Date of Birth
Name Date of Birth

Expected dates of residency for this family at the address listed above:
From: To:

I swear under pains and penalties of perjury that the answers above are true and accurate. I understand that
it is my obligation to inform the Stoneham Public Schools if there is a change in the residency of this family.

Signature of Tenant Date

COMMONWEALTH OF MASSACHUSETTS, MIDDLESEX, SS.

Commonwealth of Massachusetts County of

On this _____ day of ,20___,________________________________
Personally appeared before me, the undersigned notary public, and proved through satisfactory evidence
of identification, which were __________________________, to be the person whose name is signed on
the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its
stated purpose.

Notary Public My Commission Expires

(Please print or stamp name) Notary Seal

SPS Rev. 2019
Parent(s)/Guardian(s) Residency Certification
 Property Owner Residency Certification Form

Property Owner Information

Name Relationship to Family
Address
Home Phone Cell Phone Email Address

I am the owner of the property at , Stoneham, MA and

acknowledge that the following persons will be residing at the above address and the minor
children will be registering for school in Stoneham:

Name of Parent(s)/Guardian(s)
Home Phone Cell Phone Email Address

Please list all minor children living with the Parent(s)/Guardian(s) listed above.
Name Date of Birth
Name Date of Birth
Name Date of Birth
Name Date of Birth

Expected dates of residency for this family at the address listed above:
From: To:

I swear under pains and penalties of perjury that the answers above are true and accurate. I understand that
it is my obligation to inform the Stoneham Public Schools if there is a change in the residency of this family.

Signature of Property Owner Date

COMMONWEALTH OF MASSACHUSETTS, MIDDLESEX, SS.

Commonwealth of Massachusetts County of

On this _____day of ,20_____, ________________________________
Personally appeared before me, the undersigned notary public, and proved through satisfactory evidence
of identification, which were __________________________, to be the person whose name is signed on
the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its
stated purpose.

Notary Public My Commission Expires

(Please print or stamp name) Notary Seal

SPS Rev. 2019

Parent(s)/Guardian(s) Residency Certification