Middleburgh Central School District Thank you for taking the time to enroll your student in Middleburgh Central School's
UPK Program.
The registration packet contains information and forms necessary to enroll your student
in the UPK-three year old program and the UPK-four year old program and will ensure
they receive the assistance needed to have a successful academic career.
If you have any questions, please feel free to contact:
Grades UPK - 6:
Elementary Office (518)-827-3677
Included documents in registration packet:
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McKinney-Vento Assistance Act-Housing Questionnaire
Student Registration Form Home Language Questionnaire (HLQ) Educational History Request for Student Records (if applicable) Physical Exam Form Child & Developmental Medical History Health Certificate/Appraisal form Dental Form (Optional) In order to complete registration the following documents must be provided:
./ Parent/Legal Guardian Photo Identification
• Valid State issued ID or Valid Passport ./ Proof of Residency • Must provide Two (2) acceptable forms of proof: (examples below)
Utility bill, official payroll document from an employer, original lease
agreement, document or letter from a federal, state, or local government
agency, current property tax bill
./ Birth Certificate
• Original or Certified Copy or Valid Passport ./ Proof Of Immunization • Must be signed or stamped by a state licensed health care provider ./ Custody papers (if applicable) ./ Special Circumstances (Residency Questionnaire) • If applicable, detailing legal guardianship situations, tempora1y living
situations, custody agreements, name changes.
1
Middleburgh Central School District
Middleburgh Central School District
HOUSING QUESTIONNAIRE
Nrune of LEA:
Nrune of School:
Nrune of Student:
Last
Middle
First
Gender: D Male
Date of Birth:
/ __ / __
D Female
Month Day Year
Grade:
Phone:
Address:
ID#: - - - - - - ­
(preschool-12)
(optional)
----------­
The answer you give below will help the district determine what services you or your child
may be able to receive under the McKinney-Vento Act. Students who are protected under
the McKinney-Vento Act are entitled to immediate enrollment in school even if they don't
I
have the documents normally needed, such as proof of residency, school records,
immunization records, or birth certificate. Students who are protected under the
McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please check one box.)
D
D
In a shelter
With another frunily or other person because of loss of housing or as a result of economic
hardship (sometimes referred to as "doubled-up")
D In a hotel/motel
D In a car, park, bus, train, or crunpsite
D Other temponuy living situation (Please describe): - - - - - - - - - - - - - - ­
D In permanent housing
Print name of Parent, Guardian, or
Student (for unaccompanied homeless youth)
youth)
Date
2
Middleburgh Central School District
Signature of Parent, Guardian, or
Student (for unaccompanied homeless
Middleburgh Central School District
Proof of Residency Form
Parent/Guardian: _ __ _ __ _ __ _ _ _ Relationship to student(s): _ _ __ _ __ _ _
Name of Student: _ __ __ _ _ __ _
Gender: _ _ _ Date of Birth: _ _ ___Grade:
If registering more than 1 child you can list them here:
Name of Student: _ __ _ __ _ _ __
Gender:
Date of Birth:
Grade:
Name of Student: _ _ _ _ _ _ _ __ _
Gender:
Date of Birth:
Grade:
Name of Student: _ _ _ _ _ _ _ _ __
Gender:
Date of Birth:
Grade:
Name of Student: _ _ _ __ _ _ __ _
Gender:
Date of Birth:
Grade:
Name of Student: _ __ _ _ _ _ __ _
Gender:
Date of Birth:
Grade:
Please check one: _ Own
_Rent _ Reside with a district resident _Temporary living situation
To enroll you must reside in the school district. Solely owning property or a home does not
constitute residency.
Proof of residency is required before a student may be registered. Post office boxes will not be
accepted. You must provide at least two (2) proofs from the following list:
If you Own
•
•
•
0
0
•
•
Residing with a district
resident
If you Rent
Tax Bill w.in 30 days
House Deed
Mortgage Statement
w/in 30 days
Current Homeowner's
Insurance
Current Driver's License
Utility Bill w / in 30 days
A record of voter
recistration
•
•
•
•
Documents issued by
the federal, state or
local agencies
Utility Bill w /in 30 days
Lease agreement (must
be signed with landlords
name and phone
number)
Current Renter's
Insurance
•
Notarized letter from the
district resident along with
the resident's proof of
ownership
*A residency check will be
done by a school
representative
This document will be retained in the student's file along with other required documents. Once
this form is received by the District Registrar residency will be verified.
Parent/Guardian Signature/Date
4
Middleburgh Central School District
Approved by: Signature/ Date
Middleburgh Elementary School
Registration Form
Please choose appropriate program according to date of birth*:
 3-Year Old UPK (3 by 12/1/17)  4-Year Old UPK (4 by 12/1/17)  Kindergarten (5 by 12/1/17)
AM  PM
AM  PM
Student’s Name: _______________________________________ Sex: _____ Birth Date: ______________
Mailing Address: _________________________________________________________________________
Residence Address: _______________________________________________________________________
Birthplace: ___________________________________________ Home Language: __________________
E-mail address: __________________@___________________ Home Phone: _____________________
Has child had any prior schooling: Yes □ No □
1
If yes, please specify school name and address: _______________________________________________
_________________________________________________________________________________________
Parent Information
Parent/Guardian
Full Name:
Birth Year:
Birth Place:
Education:
Employer:
Parent/Guardian
Step Parent/Guardian
Siblings:
Parent(s) is/are:
If Separated or
Divorced,
Legal Custody with:
Date of Birth:
□ Married
□ Domestic Partners
□ Joint
□ Mom
□ Dad
□ Parent
□ Foster Care
□ Guardian
Grade:
□ Single
Residence
□ Separated
□ Divorced
RACE:
□
□
□
□
□
American Indian or Alaskan Native
Black (not Hispanic origin)
Asian or Pacific Islander
Hispanic
White (not Hispanic origin)
Signature: _______________________________________________
Date: _____________________
Relationship to Child: ____________________________________
Please note preference for am or pm does not guarantee placement.
**Application deadline for UPK Program is May 1, 2017**
Final placement will be determined by district and you will be informed by mail of your child’s placement.
The University of the State of New York • The State Education Department • Office of Bilingual Education Albany, New York 12234 Home Language Questionnaire (HLQ)
TO BE COMPLETED BY SCHOOL PERSONNEL
Please pri11/ or type clearly
DISTRICT
Dear Parent or Guardian:
SCHOOL
In order to provide your child with the
STUDENT NAlv!E
best possible education, we need to
DATE OF BIRTH
GRADE
Month:
determine how well he or she under­
STUDENT IDENTIFICATION NU!vIBER
stands, speaks, reads and writes
Day:
Year:
COUNTRY OF BIRTH I ANCESTRY
English. Your assistance in answering
NUMBER OF YEARS ENROLLED IN SCHOOL OUTSIDE THE U.S.
these questions is greatly appreciated.
NAME/POSillON OF SCHOOL PERSONNEL COMP LETING T H IS SECTION
Thank You
DETERMINATION:
0 Possible LEP
0 English Proficient
'l!+
L.
(v' boxes that apply)
1.
2.
3.
What language(s) is spoken in the student's
home or residence?
0 English
What language(s) are spoken most of the time
to the student, in the home or residence?
0 English
What language(s) does the s tudent understand?
0 English
0 Other _ _ __ _ __ __ __ _ __
specify
0 Other
specify
0 Other
specify
4.
0 English
What language(s) does the student speak?
0 Other
specify
5.
0 Does Not Read
0 Other 0 English
What language(s) does the student read?
specify
- - - - - -- - -
6.
0 English
What language(s) does the student write?
-
0 Does Not Write
0 Other specify
-- - ~-·
7. In your opinion, how well does the student understand, speak, read and write English?
VenJ well
011 ly a little
Not at all
Understands English
0
0
0
Speaks English
0
0
0
Reads English
0
0
0
Writes English
0
0
0
Month:
Signature of Pare11t/G11ardim1/0tl1er
Date Day:
Year:
HLQ (2 /00) S'J-337 PM
Middleburgh Central School District Educational History Has the student previously attended school in the Middleburgh School District?
0 Yes
D No
Does the student have an IEP (Individual Education Plan)? D Yes
D No Does the student have a 504 plan? 0 Yes
DNo Has the student participated in any of the following programs? (Check all
that apply)
D Academic Intervention Services
OReading Services
D Math Services DOther: _ _ __ _ _ _ __ _ _ __ _ _ _ _ _
Please check any special programs that your child has been assigned to
in the past:
D Consultant Services D Resource Room
D Bilingual Education
D Special Classes
D Occupational Therapy D Speech Therapy
D Physical Therapy
DCounseling
D Other
Please list all previous schools starting with the most recently attended:
School#!
Name of School:
Address:
Phone Number:
School#2
Name of School:
Address:
Phone Number:
S
Middleburgh Central School District
Middleburgh Central School District
Request for Records
Please be advised that the following student, previously enrolled in your school, has transferred
to the Middleburgh Central School District.
I hereby authorize the following information to be sent the school indicated below.
Student Information:
First Name: _ _ __ _ __
Middle Initial: Date of Birth: _ _ _ __ _ _ Grade: _ _ __ _ __ Requested Records:
Academic transcripts/report cards
Individualized Educational Plans
504 Plans
Health and immunization
Standardized test
State Test Scores
student
Regents and RCT Scores
Functional Behavioral Assessments
Social Work
Record of Birth
Discipline
Other pertinent date to ensure proper placement of
Please mail the information requested to the school/ department indicated below:
Middleburgh Central School District
Jr./Sr. High School Counseling Center
Grades 7- 12
291 Main Street, PO Box 850
Middleburgh, NY 12122
Phone: 518-827-3601
Fax: 518-827-5181
Elementary School Office
Grades PK-6
245 Main Street
Middleburgh, NY 12122
Phone: 518-827-3677
Fax: 518-827-5321
Parent/Guardian Signature._ _ _ _ _ _ __ __ _ __ _ Date: _ _ _ _ __ _
61 Middleburgh Central School District
MIDDLEBURGH ELEMENTARY SCHOOL
HEALTH CERTIFICATE / APPRAISAL FORM
Name:
Date of Birth:
School:
M F
Gender:
 Immunization record attached
 No immunizations given today
 Immunizations given since last Health Appraisal:
Grade:
IMMUNIZATIONS / HEALTH HISTORY
Sickle Cell Screen:  Positive
PPD:
 Positive
Elevated Lead:
 Yes
Dental Referral
 Yes
Negative
Negative
 No
 No
 Not done
 Not done
 Not done
 Not done
Date:
Date:
Date:
Date:
________
Significant Medical/Surgical History:  See attached
Allergies:
 LIFE THREATENING
 Food:
 Insect:
 Seasonal
 Medication:
 Other:
PHYSICAL EXAM
Height: _______________
Weight: _______________
Blood Pressure: _______________
Date of Exam:
Referral
Body Mass Index:
Vision - without glasses/contact lenses
____ ____ . ____
Weight Status Category (BMI Percentile):
 less than 5th
 85 through 94
th
th
R
L
Vision - with glasses/contact lenses
R
L
 5th through 49th
 50th through 84th
Vision - Near Point
R
L
 95 through 98
 99 and higher
Hearing  Pass 20 db sc both ears or:
R
L
th
th
 EXAM ENTIRELY NORMAL
th
Tanner:
I.
II.
III.
IV.
V.
Scoliosis:
 Negative  Positive:
Specify any abnormality (use reverse of form if needed):
MEDICATIONS
Medications (list all):
 None
 Additional medications listed on reverse of form
Name: ____________________________________________________ Dosage/Time: _________________________________________________
Name: ____________________________________________________ Dosage/Time: _________________________________________________
If AM dose is missed at home: ________________________________________________________________________________________________
I assess this student to be self-directed  Yes  No
Student may self carry and self administer medication  Yes  No
Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency
sheltering is necessary at school or if the morning medication has not been given.
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
 Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:
___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.
___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.
 Specify medical accommodations needed for school:
 None
 Known or suspected disability:
 Please monitor
 Restrictions:
 Please monitor
 Protective equipment required:  Athletic Cup
Specify current diseases:
 Asthma
 Other:
 Sport goggles/impact resistant eyewear
OPTIONAL INFORMATION, if known
Diabetes:  Type 1  Type 2
Provider’s Signature:
Phone:
Provider’s Name/Address:
Fax:
Parent Signature:
Date:
 Other:
 Hyperlipidemia
Please fax to Health Office at (518) 827-3289
 Hypertension
(Stamp below)
Child Developmental & Medical History
Student's Name:
Grade:
M/F
Birth:
Term:
Date of Birth:
Developmental:
Weight:
First tooth at age:
Sat alone at age:
Delivery:
Crawled at age:
Walked alone at age:
Conditions:
Talked at age:
Abnormalities:
1. Were problems experienced during pregnancy which required medical intervention? If so, what were they:
2. Were there any complications at birth (e.g. prolonged labor, baby's need for oxygen, premature or difficult delivery)?
3. Please note any congenital conditions present at birth:
4. Did your child proceed through the developmental stages normally?
5. Were there any particular difficulties as a preschooler (e.g. difficulty eating, sleeping, bedwetting, etc.)?
6. Any diseases, illnesses, or injuries which required medical attention?
7. Any undiagnosed illnesses (e.g. prolonged high fever, convulsions, seizures, etc.)?
8. Any hospitalizations? If so, for what reason?
9. Has your child had surgery for any reason? If yes, when and what for?
10. Have hearing or visual aids ever been required for your child? If yes, when and what for?
11. Has your child been on medication for any reason?
12. Have there been any neurological problems diagnosed on your child birth to present? If so, please explain.
13. Attention problems or hyperactivity problems? _____ Has medication been prescribed?
If so, name of medication and when started:
14. Previous or current cancer treatments? _____ Please explain:
15. Please explain any other pertinent medical, dental or psychological history:
16. Is your child a twin? If yes, birth order: Twin 1: ______________________ Twin 2: ____________________________
Middleburgh Central School
Child Developmental & Medical History
Illness:
Chicken Pox
Scarlet Fever
Pneumonia
Bronchitis
Breathing Difficulties
Blood Disorders
Rheumatic Fever
Kidney Problems
Tuberculosis
Family History of T.B.
Contact with T.B.
Heart Disease
Heart Murmur
Scoliosis
Frequent Nosebleeds
Food Allergies (please list)
Lactose Intolerant
Other
Has your child had the following? (Please check  and list date(s):
Illness:

Date:

Diabetes
Hepatitis
Seizures (List type)
Asthma
Allergy to bee stings
Family history of bee allergy**
Frequent earaches
Frequent colds
Frequent Strep Throat
Ear Condition
Ear Tubes
Vision Difficulties
Cataracts
Speech Difficulties
Emotional Problems
Behavioral Problems
Frequent Headaches
Epilepsy
**Type of Reaction to Bee Sting
Date:
Regarding Allergies:
Does your child have allergies? _____ If yes, what? _______________________________________________________________
Does your child require medication for these allergies? _____ Please name medication: ___________________________________
Does your child require medication to be kept in school? _____ Please name medication: ___________________________________
Please note that regarding medications in school, both a signed doctor’s note and a parent note are necessary in order for the school nurse to
administer the medication.
Are immunizations up-to-date? _____
Family Doctor: ______________________________________________________ Phone: _____________________
Family Dentist: ______________________________________________________ Phone: _____________________
__________________________________________________________
Parent Signature
Middleburgh Central School
__________________________________
Date
Dental Health Certificate- Optional
Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry,
K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete
Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your
dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Last
Child’s Name:
Birth Date:
/
Month
School:
/
Day
First
Sex:
Year
Male
Middle
Will this be your child’s first visit to a dentist?
Yes
No
Female
Name
Grade
Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities?
Yes
No
I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this
assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for
my child to receive a complete dental examination with x-rays if necessary to maintain good oral health.
I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship.
Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the
recommendations listed below.
Parent’s Signature______________________________________________________________ Date
Section 2. To be completed by the Dentist
I. The Dental Health condition of _______________________________ on _________________ (date of exam) The date of the
exam needs to be within 12 months of the start of the school year in which it is requested. Check one:
Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.
No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.
NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus
on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit
condition of dental health to permit attendance at the public school does not preclude the student from attending school.
Dentist’s name and address (please print or stamp)
Dentist’s Signature
Optional Sections - If you agree to release this information to your child’s school, please initial here.
II. Oral Health Status (check all that apply).
Yes
Yes
Yes
No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a
tooth that is missing because it was extracted as a result of caries OR an open cavity].
No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to darkbrown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces.
If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are
considered sound unless a cavitated lesion is also present].
No Dental Sealants Present
Other problems (Specify):_______________________________________________________________________________
III. Treatment Needs (check all that apply)
No obvious problem. Routine dental care is recommended. Visit your dentist regularly.
May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.
Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.