379 Boulevard, Hasbrouck Heights, NJ 07604
(201) 288-6150
HASBROUCK HEIGHTS PUBLIC SCHOOLS
REGISTRATION FORM
Student’s Name:
SECTION A: If the student is living with a parent or guardian whose
permanent home is the address listed on page 1 of this application and is located in the district.
SECTION B: If the student is living with a person domiciled in the district, other than the parent or guardian. (“Affidavit Student”)
SECTION C: If the student is living with a parent or guardian temporarily residing within the district.
SECTION D: If the student’s situation is not addressed by Section A,B or C or if any of the circumstances in Section D apply (Special Circumstances)
Please check the appropriate section A,B,C or D, according to the situation best matching the student’s circumstance.
If you have any questions regarding the completion of the attached forms kindly contact the appropriate secretary listed below:
Euclid School - Pat Carlin 201-393-8176
Lincoln School - June Raymond 201-393-8182
Middle School - Fran DelVecchio 201-393-8190
High School - Pat Kunzmann 201-393-8164
REGISTRATION FORM
Date:_________________ School:_____________________________________
Student:
Last Name First Name Middle Name
Age: Date of Birth:____________________ Male:____
Female:____
City of Birth: State of Birth:
Country of Birth (if other than the USA):
Race (please check): Hispanic American Indian
Asian Black
Pacific Islander White
Name of Parent(s)/Guardian(s):
Person Enrolling Student:_________________________________________________________
Relationship to Student If Other Than Parent:_________________________________________
Child Lives With (circle one): Both parents Mother Father Guardian
Student’s Physical Address:______________________________________________________________________
Mailing Address (if different):_____________________________________________________
Home Telephone (Including Area Code):_____________________________________________
Other Phone or Fax (if any):_______________________________________________________
Parent(s)/Guardian(s) Physical Address:______________________________________________________________________
Mailing Address (if different): ____________________________________________________
_____________________________________________________________________________
Are you and your child currently homeless?
Home Telephone (including area code):______________________________________________
Other Phone or Fax (if any):_______________________________________________________
Native Language of Parent/Guardian/Person Enrolling Student: __________________________
Is English Spoken and Understood By Parent/Guardian/Person Enrolling Student? Yes_________
No __________
Native Language of Student: ______________________________________
Is English Spoken and Understood By Student? Yes _____ No _____
Is your child currently covered by Health Insurance? Yes No
If yes, who is his/her health care provider?
Date of your child’s last medical examination (attach proof):
Date of your child’s last dental examination (attach proof): ________________________
Date of your child’s last lead test:
Lead Level:
Date of your child’s polio immunization:
Proof of Residency: (Copy of one document required)
- Property Tax Bill _____ 4. Lease _____
- Deed _____ 5. Mortgage _____
- Contract of Sale _____ 6. Signed Letter From Landlord
How long have you lived in this residence? ___________
Please list four forms of proof as evidence of personal attachment to the address given as your residence such as Voter registrations, licenses, permits, financial account information, utility bills, delivery receipts, and other evidence of personal attachment to the address given:
1. ________________
2. ________________
3. ________________
4. ________________
Also, please provide a photo identification:
Driver’s License __________ Employee __________
County Residency _________
Other _____________
Student Information:
Birth Certificate _____
Transfer Card _____
Immunization Record _____
Most Recent Report Card _____
Name & Address of Previous School : ____________________
____________________________________________________
REGISTRATION FORM (cont’d)
Educational Services — Previous School
Classified Student ______
504 Student _____
Speech/Language _____
Basic Skills Instruction ______
ESL Program _____
PAC Program _____
Other Program Offerings _____
Explain: ______________________________________________________________________________
______________________________________________________________________________
If High School student, list athletic teams in which you have participated:
1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________
Signature of person enrolling student: _______________________________________________
(For Administrative Use Only)
School Placement & Grade
Euclid School Grade ___________________________
Lincoln School Grade __________________________
Middle School Grade ___________________________
High School Grade______________________________
Out of District Placement ________________________
Pre-School _____________________________________
Special Services (Explain): _________________________________________________
________________________________________________________________________
Application Processed by: Date; _____________
Principal’s Signature: Date:
Superintendent of Schools: _______________________________Date: ________________
updated 8.13.08