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Student Registration Form Fillable

The document is a Student Registration Form that collects essential information about a student named Carlos Alberto Franco, including personal details, health insurance, and special education needs. It also requires parent/guardian information and includes sections for enrollment staff to complete regarding registration status and documentation presented. The form is designed for official use in the NYC Department of Education.

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Jeni Amador
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© © All Rights Reserved
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7 views

Student Registration Form Fillable

The document is a Student Registration Form that collects essential information about a student named Carlos Alberto Franco, including personal details, health insurance, and special education needs. It also requires parent/guardian information and includes sections for enrollment staff to complete regarding registration status and documentation presented. The form is designed for official use in the NYC Department of Education.

Uploaded by

Jeni Amador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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For Official Use

 ES  MS  HS
Student Registration Form  GE  SE  ELL

To Be Completed by Parent/Guardian:
Student Information

STUDENT NAME: LAST


LAST NAME FIRST NAME MIDDLE NAME STUDENT ID #
Franco Carlos Alberto
HOME ADDRESS (House number, Street name, Apt #, City, State, ZIP) HOME PHONE NUMBER
214. Bement avenue Staten Island New York. 10310 ( )
DATE OF BIRTH (mm/dd/yyyy) AGE GENDER (optional) PLACE OF BIRTH HOME/NATIVE LANGUAGE
08/22/2004 M ✔ F Santo Domingo Spanish
NAME, CITY, STATE OF LAST SCHOOL (or current school) LAST GRADE COMPLETED
Cristo Obrero, Santo Domingo norte, 11 grade
HEALTH INSURANCE INFORMATION: Does the student have health insurance? HEALTH ALERT: Any health condition that
 YES  If YES, what type of coverage is it?  Private Health Insurance  Medicaid  Child Health Plus B affects participation in physical activities.
 NO  If NO, would you like to be contacted about getting coverage?  Yes  No  Yes 
✔ No

SPECIAL EDUCATION INFORMATION: Does the student receive special education services?
 YES  If YES, do you have a copy of the Individualized Education Plan (IEP)?  Yes  No
 NO

Parent/Guardian Information
LAST NAME FIRST NAME RELATIONSHIP TO STUDENT

Franco Carlos Father


HOME ADDRESS (House number, Street name, Apt #, City, State, ZIP) PARENT/GUARDIAN PREFERRED LANGUAGE

214 Bement avenue Staten Island New York 10310 WRITTEN: English SPOKEN: English

HOME PHONE NUMBER WORK/CELL PHONE NUMBER PARENT/GUARDIAN EMAIL


( ) 7182133269 ( ) 2122478000 [email protected]

FIRST
To Be Completed by Enrollment Staff:
Registration (check one): Disposition:
 New
 Re-admit to NYC DOE (less than 1 year)
 Re-admit to NYC DOE (longer than 1 year)
 Code 10 Return (If Code 10 Return): Enrolled School Name DBN
 Student has current transcript
 Transcript request made to out-of – Referred to:
New York City school School Name DBN
Transfer Request (check one):
1)
 Safety
 Medical
2)
 Travel (HS only)
 Child Care (ES only)
3)
 Sibling (ES only)
 Other (please specify):
DATE:

Notes:

I have met with a counselor and understand my options and the process for school placement. I understand the information presented
and have received the information necessary to proceed.

Name/Signature of Parent/Guardian: Date: 09 /13/2021


Name/Signature of Counselor:
Additional Comments:
To Be Completed by Enrollment Staff:

Name of Staff Completing Registration:

STUDENT NAME: LAST


Documents Presented (Check all that apply)
Proof of residence may be verified by any two of the following:
 Residential Utility Bill (electric/gas issued by National Grid, Con Edison or the Long Island Power Authority; must be dated within the past 60 days
 Documentation or letter on letterhead from a federal, state or local government agency, including the Internal Revenue Service (IRS), City Housing
Authority, Human Resources Administration (HRA), the Administration for Child Services (ACS), or an ACS subcontractor indicating that resident’s
name and address; must be dated within the past 60 days
 An original lease agreement, deed, or mortgage statement for the residence
 A current property tax bill for the residence
 A water bill for the residence; must be dated within the past 90 days
 Official payroll documentation from an employer such as a form submitted for tax withholding purposes or payroll receipt; a letter on the employer’s
letterhead will not be accepted; must be dated within the past 60 days
 Parent Affidavit of Residency, if applicable, as per CR A-101
Proof of Birth:  Birth Certificate  Passport  Other:
 Transcript/Report Card  Doctor’s Letter  Agency Letter
 Immunization Records  Occurrence Report  Notarized letter from employer
 IEP (Individualized Education Program)  Safety Transfer Summary of Investigation  504 Accommodation Plan
 Parent Affidavit  Safety Transfer Intake Form  Other (Specify: )
 Non-Parent Custodian Affidavit  Police Report/Docket #  Other (Specify: )
 Affidavit of Emancipation  Court Documentation  Other (Specify: )
 Transfer Form (“T-Form”)  Notarized letter from child care provider  Other (Specify: )
* Updated proof of address requirements are reflected in Chancellor’s Regulation A-101.

Interview Notes (Please Include all applicable information):


School History: Grade Level, Credits, Test scores, Choice Process participation, Regents/RCTs, Discharge Info, HSAPs Info
Entitled Services: Special Education Services, ELL Services, etc.
Special Circumstances: Agency Involvement/Contact, Temporary Housing, Foster Care, etc.

FIRST
School Interests: Parent Preferences, Academic Interests, Requests

To be completed by Enrollment Counselor, if applicable:


 Indicate if any court order exists which affects a parent’s access to the student’s records:
Name (first & last): Documentation Presented (court order, etc.):
DATE:

STATUS OF DISPOSITION (Check one):  Registered  Referred  No Action  Info Given  Pending
 Other (Specify):
Comments:

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