Download - Reg Packgpworking71811
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The Registration Process
Print and complete all registration documents and bring them to the Franklin
Township Board of Education office of Student Registration located at 1755 Amwell
Road, Somerset, New Jersey along with the items listed below.
1. A valid birth certificate/passports are acceptable (cannot be expired)
2. Two Proofs of Residency in Franklin Township (a combination of the following: current lease, deed, mortgage statement, property tax statement and a utility bill-
PSEG, Water, Sewer) If you are living with someone in the district, you must
print and complete a Residency Affidavit and have it notarized. In addition
to the Residency Affidavit you must supply proof that the individual listed as
the homeowner or tenant is a Franklin resident. You must bring two forms
of residency documentation for the homeowner or tenant and one for the
parent/guardian registering the student.
3. Proof of all updated immunization records (please note that all immunizations must be signed or stamped from the doctors office to be considered official)-
As per New Jersey Administrative Code Citation 8:57-4.2-A principal,
director or other person in charge of a school, pre-school, or child care
facility shall not knowingly admit or retain any child whose parent or
guardian has not submitted acceptable evidence of the childs immunization,
according to the schedules specified in this subchapter. 4. Last/most recent Report Card, Transcript of grades, credits earned, State
I.D.# (if transferring from a NJ public school), and standardized test results
such as (GEPA, Terra Nova, etc.). Although the former school district is expected
to forward academic information to the new school district upon notification of
enrollment, it is helpful if copies of standardized test scores and the latest report
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card are presented at the time of registration. Please be prepared to share the
name, address and phone number of your child's former school.
5. Photo Identification for parent or guardian registering the child.
6. If you are not the parent or legal guardian of the child, you must provide proof of
guardianship established by NJ Surrogate Court or DYFS placement.
7. If your child is or has been evaluated by any Special Education Committee, you
must bring the most recent copy of the childs IEP (Individual Educational Plan)
Note: After the registration process has been completed, our office will notify the Transportation Office and you should receive information from them stating your childs eligibility for bus service. If you have any questions regarding the registration process, please contact the Parent Information Center/Office of Student Registration.
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Franklin Township Public Schools1755 Amwell RoadSomerset, NJ 08873Registration FormSmiD#:
Student Information/Information del Estudiante:
Gender: D Male/Hombre D Female/Mujer
State ID#:
Birth Date/Fecha de Nacimiento:
Last Name/Apellido First Name/Nombre Middle Initial/Segundo Nombre
Address/Direccidn
Birth Place/Lugar de Nacimiento:
City/State/Ciudad/Estado Zip Code/Codigo Postal
City/State or Country/ Ciudad/Estado o Pals
Is the student receiving Special Education Services? Esta el niflo (a) recibiendo Servicios de Educacion Especial?Yes/Si No
Ethnicity/Grupo Etnico (check all that apply/seleccionar todo que aplique):D American Indian or Alaska Native/Indio Americano o Nativo de Alaska ~ Asian/Asiatico D Black or African American/Afro-Americano Hispanic/Hispano j Native Hawaiian or Other Pacific Islander/Nativo de Hawai o Otro Nativo de las Islas Pacificas White/Blanco
Parent/Guardian Information:Informacton del Padre/Guardian:
Last Name/Apellido First Name/Nombre Relationship/Relacion
Address if different from above/Direcci6n si es diferente City/State/Ciudad/Estado
Phone #'&:
Zip Code/Codigo Postal
# De TeleTonos: Home/Casa Work/Trabajo Cell/Celular Email/Correo Electrtinico
Check here if the person listed above should be or is the Emergency Contact LSeleccionar la caja, si la persona nombrada arriba es o deberia ser el Contacto de Emergencia
Last Name/Apellido First Name/Nombre Relationship/Relacion
Address if different from above/Direcci6n si es diferente City/State/Ciudad/Estado
Phone #'s:
Zip Code/C6digo Postal
# De TeleTonos: Home/Casa Work/Trabajo Cell/Celular Email/Correo Electrdnico
Additional Information:Please list Siblings and School they attend:Favor de listar a hermanos (as) y la escuela que asisten:
Last Name/Apellido
Last Name/Apellido
Last Name/Apellido
First Name/Nombre
First Name/Nombre
First Name/Nombre
School/Escuela
School/Escuela
School/Escuela
High School Students/Estudiantes de Escuela Secundaria:
What year did the child graduate from 8th grade?En que ano se graduo el nino (a) de primaria o 8vo grado?
Has your child ever attended a High School? Ha asistido su hijo (a) a una Escuela Secundaria?Yes/Si NoIf so, what is the Name? Cual es el nombre de la escuela? state/estado? que aflo?
Is your child in any vocational program or plans to be in one? Esta su hijo (a) en algiin programa vocacional o esta planeando asistir a uno?Yes/Si No
Parent/Guardian Signature/ Firma del Padre/Guardian:
OFFICE USE ONLYSchool AssignmentPrior SchoolTransfer Code
Current GradeSchool ID
Transfer Card? YGNjBirth Certificate? YONuReturning Student Y D N DTransportation Notified? YDND
Residence Documentation? YDNuGuardianship Documentation? YCNi]Free or Reduced Lunch? YDND
Verification of Birth Date? Y N ~jIs this a "bona fide change of residence? Y N D
Registration Completed By: Registration Date:
GEPEATICKSticky NoteMigrationNone set by GEPEATICK
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Franklin Township Public SchoolsPreK-12 Home Language Survey
Student Information (Please Print) Student ID#:First Name Last Name Date ot Birth Genaer
D Female D MaleCountry of Birth Date ofbntry in U.S. Date first enrolled in any U.S. school Ethnicity
D White Black D Latino AsianD Pacific Islander D American Indian
School Information (To be completed by office personnel)School Current tirade Enrollment Date Evaluated by: (Bilingual / fcJSL Teacher)
Date WAPT Placement Exam was
administered
Primary Language
Eligibility - Based on the WAPT Placement Exam results, the student is:
D Not eligible for ESL / Bilingual Services Eligible for ESL services only (Date placed into program) Eligible for Bilingual and ESL services (Date placed into program)
In which language do you wish to receive
school communication? English Spanish Gujarati
Questions for Parents / Guardians (Please Print)1
2
3
4
5
6
7
8
9
Who is the person completing the survey?
What language did the child learn when he/she first began to talk?
What language does the family speak at home most of the time?
What language does the mother [guardian] speak to the child most of thetime?What language does the father [guardian] speak to the child most of thetime?
What language does the child speak to his/her mother most of the time?
What language does the child speak to his/her father most of the time?
What language does the child speak to her/her brothers and sisters mostof the time?What language does the child speak to his/her friends most of the time?
Response Mother Father D Grandparent Guardian Other
D English D Spanish D Gujarati OtherD English D Spanish D Gujarati Other
D English D Spanish D Gujarati OtherD English D Spanish D Gujarati Other
D English D Spanish D Gujarati OtherD English D Spanish D Gujarati Other
D English D Spanish D Gujarati OtherD English D Spanish D GujaratiD Other
Please list any previous schooling1
2
Name ot School
Grades Completed
Name ot School
Grades Completed
Dates ot Attendance
Dates ot Attendance
Location (City / Country)
Language ot Instruction
Location (City / Country)
Language ot Instruction
Previous ESL / Bilingual ProgramSchool Grades Attended Dates Attended
Signature:
White - Director
(Person completing this survey)
Canary - ESL Teacher
Date:
Pink - School
(today's date)
Franklin Township Public Schools
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FRANKLIN TOWNSHIP PUBLIC SCHOOLSSomerset (Somerset County), New JerseyHome Contact / Emergency School Closing Contact Card - School YearStudent's Last Name First Name Middle Name Grade
Teacher
RELATIONSHIP - MOTHER / GUARDIAN
Last Name First Name
Address
Telephone
Middle Name
City
Alt. Telephone Ext.
Title
State Zip Code
Birthdate (optional)
Employer
Work Address
Work Telephone Ext. Work HoursFrom
City Stale
To
Zip Code
E-mail Address:
RELATIONSHIP- FATHER /GUARDIAN
Last Name First Name
Address
Telephone
Middle Name
City
Alt. Telephone Ext.
Title
State Zip Code
Birthdate (optional)
Employer
Work Address
Work Telephone Ext. Work HoursFrom
City State
To
Zip Code
E-mail Address:
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Student's Last Name First Name Middle Name
OTHER CONTACTSList two alternative people who have agreed to assume lull responsibility for your child as defined in the Emergency SchoolClosing Standard Operating Procedure.
First Contact
Address
Telephone Ext.
City-
Secondary Contact
Address
Relationship to Student
State
Telephone Ext.
City
Zip Code
Relationship to Student
State Zip code
EMERGENCY CONTACTS - IN CASE WHERE PARENT (S) CANNOT BE REACHED, PLEASE LIST ALTERNATE.
Medical Alert 1 Medical Alert 2
Physician Telephone Ext.
Does your child have medical insurance? Yes No
Can you be contacted by New Jersey Family Care? Yes No
If none of the above can reached, what do you wish the school to do in case your child is sick or injured?Please Complete:
* (It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. TheRecommendation of the parent as indicated above will be respected as far as possible.
My child is NOT capable of self-care in the event of an Emergency School Closing. l want to be called: M do not need to be called.
Signature: Mother/Guardian: Father/Guardian:
Bus No: __ or Walker. If your child is in an after school program, indicate the name of the program:
Phone number:
If there is a legal separation in the family, the school district requires legal documentation that indicates which of the parentsHas legal custody of the child. In the absence of such documentation, the school district will honor the custodial rights ofeither parent. Please complete the remainder of this section, if applicable.
Yes, there is a legal separation (please check) Q
Parent has submitted for review appropriate documentation to the principal that indicates which parent may or may not signthe child out of school and/or have access to records.
Parent/ Guardian Signature: Date:
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Franklin Township Public Schools 1755 Amwell Road, Somerset, NJ 08873
Tel: (732)-873-2400 ext 401; Fax: (732) 873-8393 Parent Information Center/Office of Student Registration
The child whose name appears below has registered at a school within our school district. Will you please send cumulative records, health records, test records, psychological reports, and any additional information you may have concerning their progress to the school indicated below. Thank you for your cooperation. Childs Name: __________________________________________ Previous Grade: _______
PARENTS CONSENT FOR TRANSFER OF RECORDS
The ____________________________________________ School District has my permission to (DISTRICT TRANSFERRING FROM) transfer the full student (s) records, including achievement, behavioral and psychological, for ALL students listed above to Franklin Township Public Schools. I understand that I may review these records, in accordance with the provisions of the Family Educational Rights and Privacy Act of 1974. _______________________________________________________________________________________
ADDRESS OF PREVIOUS SCHOOL Signature of Parent/Guardian _________________________________________ Date________ Print Name of Parent/Guardian __________________________________________________
*PLEASE SEND STUDENT RECORDS TO THE FOLLOWING SCHOOL*
Conerly Road School-Grade PK-4
C.V Bush - Secretary 35 Conerly Road, Somerset, NJ. 08873 (P) 732-249-9362 (F) 732-247-7076
MacAfee Road School-Grade PK-4 Patsy Hooper - Secretary
53 MacAfee Road Somerset, NJ. 08873 (P) 732-249-9097 (F) 732-247-1408
Elizabeth Ave School-Grade PK-4 Pat Sanchez - Secretary
363 Elizabeth Ave Somerset, NJ. 08873 (P) 732-356-0113 (F) 732-271-2534
Pine Grove Manor School-Grade PK-4 Sharon Pron - Secretary
130 Highland Avenue Somerset, NJ. 08873 (P) 732-246-2424 (F) 732-843-5572
Franklin Park School-Grade PK-4 Judy Nocero - Secretary
30 Eden Street, Franklin Park, NJ. 08823 (P) 732-297-5666 (F) 732-297-5834
Sampson G. Smith School Grade 5-6 Michelle Moskal - Secretary
1649 Amwell Road Somerset, NJ. 08873 (P) 732-873-2800 (F) 732-873-0451
Franklin Park Annex/ child Develop. Center Jo-Ann Piagentinni - Secretary
1 Central Avenue Franklin Park, NJ. 08823 (P) 732-297-3427 (F) 732-940-8931
Franklin Middle School Grade 7-8 Noreen Leib-Secretary
415 Francis Street Somerset, NJ.08873 (P) 732-249-6410 (F) 732-246-0770
Hillcrest School-Grade PK-4 Terri Levy & Luisa Flintoff - Secretary
500 Franklin Blvd Somerset, NJ. 08873 (P) 732-246-0170 (F) 732-247-8405
Franklin High School Grade 9-12 Patricia Naulty & Evelyn Pemberton Secretary
500 Elizabeth Avenue Somerset, NJ. 08873 (P) 732-302-4200 (F) 732-302-4212
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Franklin Township Public Schools 1755 Amwell Road, Somerset, NJ 08873
Tel: (732)-873-2400 ext 401; Fax: (732) 873-8393 Parent Information Center/Office of Student Registration
Pierina De La Cruz, Coordinador of Parent Information Center The child whose name appears below has registered at a school within our school district. Will you please send cumulative records, health records, test records, psychological reports, and any additional information you may have concerning their progress to the school indicated below. Thank you for your cooperation. Nombre del Nio (s): __________________________________________ Grado Previo: ____
CONSENTIMIENTO DE PADRES PARA INTERCAMBIO DE ARCHIVOS
El Distrito Escolar de __________________________________________ tiene (El DISTRITO PREVIO)
mi autorizacin para Intercambiar los archivos del estudiante (s), incluyendo reportes de progreso, comportamiento y psicolgico, para TODOS los estudiantes nombrado anteriormente al Distrito Escolar del Municipio de Franklin. Yo entiendo que yo puedo revisar estos archivos, acordados en las provisiones de los Derechos Educacionales de Familias y El Acto de Privacidad del 1974.
_____________________________________________________________________
DIRECCIN DE ESCUELA PREVIA Firma del Padre/Guardin __________________________________ Fecha ________ Escribir el Nombre del Padre/Guardin ______________________________________
*PLEASE SEND STUDENT RECORDS TO THE FOLLOWING SCHOOL*
Conerly Road School- Grade PK-4 Donna Lucash & C.V Bush - Secretary
35 Conerly Road, Somerset, NJ. 08873 (P) 732-249-9362 (F) 732-247-7076
MacAfee Road School-Grade PK-4 Fee Valeri Stark & Patsy Hooper - Secretary
53 MacAfee Road Somerset, NJ. 08873 (P) 732-249-9097 (F) 732-247-1408
Elizabeth Ave School-Grade PK-4 Janet Flissar & Pat Sanchez -Secretary 363 Elizabeth Ave Somerset, NJ. 08873
(P) 732-356-0113 (F) 732-271-2534
Pine Grove Manor School-Grade PK-4 Sharon Pron - Secretary
130 Highland Avenue Somerset, NJ. 08873 (P) 732-246-2424 (F) 732-843-5572
Franklin Park School-Grade PK-4 Judy Nocero & Rosetta Stevenson -Secretary
30 Eden Street Franklin Park, NJ. 08823 (P) 732-297-5666 (F) 732-297-5834
Sampson G. Smith School Grade 5-6 Michelle Moskal & Debra Hentz - Secretary 1649 Amwell Road Somerset, NJ. 08873
(P) 732-873-2800 (F) 732-873-0451
Franklin Park Annex/ child Develop. Center Jo-Ann Piagentinni - Secretary
1 Central Avenue Franklin Park, NJ. 08823 (P) 732-297-3427 (F) 732-940-8931
Franklin Middle School Grade 7-8 Noreen Leib-Secretary
415 Francis Street Somerset, NJ.08873 (P) 732-249-6410 (F) 732-246-0770
Hillcrest School-Grade PK-4 Terri Levy & Luisa Flintoff - Secretary
500 Franklin Blvd Somerset, NJ. 08873 (P) 732-246-0170 (F) 732-247-8405
Franklin High School Grade 9-12 Patricia Naulty & Evelyn Pemberton Secretary
500 Elizabeth Avenue Somerset, NJ. 08873 (P) 732-302-4200 (F) 732-302-4212
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Franklin Township Public Schools Parent Information Center/Centro de Informacion Para Padres
1755 Amwell Road, Somerset, NJ 08873 Tel: (732) 873-2400; Fax: (732) 873-8393
Parent Affidavit of Residency/Declaracion Jurada de Residencia
If a parent is subletting an apartment or home, or if more than one family shares a living space and there is only one leaseholder or homeowner, the parent must present a notarized Address Affidavit signed both by the primary leaseholder as well as the parent affirming that the family is residing in this home, and must attach the lease, and/or utility bill (PSEG). Si un padre no tiene contrato de alquiler, o ms de una familia comparten una vivienda y hay un solo dueo/a, el padre tiene que presentar este formulario notariado Declaracin Jurada firmado por el dueo/a y el padre afirmando que la familia reside en esta direccin, adjunto debe estar el contrato de alquiler del dueo/a o cuenta de electricidad.
Section A: Students Information/Informacion del Estudiantes- Print/Letra de Molde
LAST NAME/APELLIDO NAME/NOMBRE GENDER/SEXO DOB/FECHA DE NACI. 1. 2. 3. 4. 5.
Section B:Parent/Guardian Information/Informacion del Padre- Print/Letra de Molde PARENTS LAST NAME/APELLIDO DEL PADRE NAME/NOMBRE PARENTS CURRENT ADDRESS/DIRECCION DEL PADRE HOME PHONE/# DE LA CASA WORK PHONE/# DE TRABAJO CELL PHONE
Section C: Owner, Leaseholder/Dueo/a, o Inquilino Primario-Print/Letra de Molde OWNERS LAST NAME/APELLIDO FIRST NAME/APELLIDO OWNERS CURRENT ADDRESS/DIRECCION ACTUAL DEL DUENO HOME PHONE/# DE LA CASA WORK PHONE/# DE TRABAJO CELL PHONE RELATIONSHIP TO PARENT/RELACION AL PADRE
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To be completed by parent/Para ser completado por el padre: I, _______________________________, the parent of ___________________________ Yo , el padre de (Nombre del Estudiante) hereby affirm that I am residing with _________________________________________ afirmo que resido con at the following address ____________________________________________________ en la siguiente direccin I understand that Franklin Township Public Schools has the right to conduct an Attendance Investigation to verify my residence including a visit to the home of the primary leaseholder. I also understand that registration in school is based on eligibility determined by my residence, and Franklin Township Public Schools has the right to transfer students for whom falsified documentation was provided at the time of registration. In the event that my residency changes, I agree to notify the district and present new proof of address. Yo entiendo que Las Escuelas Publicas del Municipio de Franklin tienen el derecho de conducir una investigacin de asistencia incluyendo una visita a la vivienda del dueo/a. Yo tambin entiendo que la inscripcin esta basada en la elegibilidad determinada por donde vivo, y que el distrito tiene el derecho de transferir cualquier estudiante que se halla provedo falsa documentacin al tiempo de inscripcin. Si mi residencia cambia, yo soy responsable de informarles y someter nueva prueba de direccin. To be completed by Primary Leaseholder/Owner: Para ser completado por el Dueno/a: I hereby affirm that______________________________________________________________ Yo afirmo que (Name of Parent and Child-ren) (Nombre del Padre y Estudiante-s) are residing with me at ___________________________________________________________ residen conmigo en (insert address) (direccin) I understand that Franklin Public Schools has the right to conduct an Attendance Investigation to verify the residence of the parties named in this affidvit, including a visit to my home and interviews with my neighbors. I can be contacted at the number (s) listed below should the District require further information. Yo entiendo que Las Escuelas Publicas del Municipio de Franklin tienen el derecho de conducir una investigacin de asistencia para la verificacin de vivienda de las personas nombradas en esta declaracin incluyendo una visita a mi hogar e interrogar a mis vecinos. Me pueden contactar en los nmeros de telfonos enlistados aqu si el distrito necesita ms informacin. Signatures/Firmas: Parent Signature/Firma del Padre: _____________________________________________ Primary Leaseholder/Firma del Dueo/a: __________________________________________ State of New Jersey SS: County of __________________________________ Sworn to before me this ___________ day of _________________________, Year ___________ ____________________________________________________ Notary Public
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FRANKLIN TOWNSHIP PUBLIC SCHOOLS NJ Family Care Health Insurance
Dear Parent/Guardian: More than a quarter-million New Jersey children lack health insurance, and that number is likely to grow as the economy deteriorates. If our child does not have health insurance you may qualify for low cost or no cost health insurance through the NJ FamilyCare Program. NJ FamilyCare is not a welfare program, but rather the State of New Jerseys way of providing affordable health coverage for kids and certain low-income parents. NJ FamilyCare is a federal and state funded health insurance program created to help New Jerseys uninsured children and certain low-income parents and guardians to have affordable health coverage. NJ FamilyCare is for families who do not have available or affordable employer insurance, and cannot afford to pay the high cost of private health insurance. How to qualify can be viewed in 12 languages, and the entire application process can be completed by mail or online. All enrollment packets contain postage free envelopes. To find out if you qualify for NJ FamilyCare call 1-800-701-0710, for hearing impaired individuals TTY 1-800-701-0720. Multi-lingual operators are available and calls are accepted Mondays and Thursdays between 8:00 a.m. & 5:00 p.m. You may also apply online at www.njfamilycare.org. NJ FamilyCare Advantage is another low cost health insurance program offered through Horizon NJ Health that your family may be eligible for. To qualify you must meet the following guidelines:
Without health insurance for more than six months Your children must be under the age of 19 Eligibility id based upon household income and the number of people in your
family If you have questions about the NJ FamilyCare Advantage program call the Horizon NJ Health Outreach Center at 1-800-637-2997. You may call toll free from 8:00 a.m. until 7:00 p.m. Monday through Friday. You may access the NJ FamilyCare Advantage program online at www.horizonnjhealth.com as well. You may also contact your school nurse for any questions or assistance regarding healthcare insurance for your child.
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IMM-19 (Side 1)SEP 06
New Jersey Department of Health and Senior ServicesVaccine Preventable Disease Program
PO Box 369Trenton, NJ 08625-0369
ANNOUNCINGTHE NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)
To New Jersey Parents and Guardians:
In order to attend any licensed day care, preschool, public, parochial or private school in NewJersey, your child must meet state mandated immunization requirements. A record of theseimmunizations, supplied by your healthcare provider, is maintained by the school on a stateapproved form (A45). This record is essential for admission to any new school to which your childtransfers, for entrance into high school and for college entrance. The New Jersey ImmunizationInformation System (NJIIS) has been developed to provide a confidential population-basedelectronic database that collects and stores vaccination data for New Jersey residents. This registryis already in use at more than 400 sites throughout New Jersey, with more than 600,000 patientrecords currently in the system. The immunization Information System is the first step in creatingelectronic health records for New Jersey school students.
New Jersey public schools are assisting in this project by inputting data from the studentsImmunization Record. Participation in this program is free and will provide you with a permanentrecord of your childs immunizations, as well as reminders of the need for any additional doses. Itwill exist for your child long after graduation when immunization records may be needed for foreigntravel or other situations. It will be available to you for summer camp requirements and should youchange healthcare providers.
Your childs immunization record is confidential. It is available only to you, the Health Departmentand its related service agencies (your childs school) and the health provider(s) you choose. If youchange providers, only the new provider will be able to send you reminders.
To enroll in the system, simply sign the consent form on the back of this letter and return it to yourchilds school nurse within seven days.
If you have any questions, you may call your childs school nurse.
We hope that you will take advantage of this opportunity to promote the well being of your child.
PLEASE COMPLETE THE REVERSE SIDE OF THIS SHEET ANDRETURN IT TO YOUR CHILDS SCHOOL NURSE!
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IMM-19 (Side 2) SEP 06
NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)
CONSENT TO PARTICIPATE
CHILD INFORMATION (please print) PARENT/GUARDIAN INFORMATION Name
Name
Date of Birth
Relationship
Address
Address
I have read the information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to keep a central record of my childs immunization history and to remind me when immunizations are due. I understand that I can obtain a copy of my childs record from my medical provider, my local health department, or my childs school nurse.
There is no cost to participate in this program.
Yes, I would like to participate in this program.
No, I do not wish to participate in this program.
Signature of Parent / Guardian
Date
New Jersey Department of Health and Senior Services Vaccine Preventable Diseases Program
PO Box 369 Trenton, NJ 08625-0369
PLEASE RETURN THIS FORM TO YOUR CHILDS SCHOOL NURSE WITHIN 7 DAYS
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FRANKLIN TOWNSHIP PUBLIC SCHOOLS Nursing Services/Servicios de Salud
Date/Fecha: _______________________ Dear Parent/Guardian: There have been new laws enacted to protect the privacy of student health information. In order to be in compliance with the Family Educational Rights and Privacy Act (FERPA), we must have the parents/guardians permission to share medically related information with appropriate staff members at the school. This medically related information would include, but would not be limited to, information on allergies, history of asthma, medication, hearing/vision problems, seizures, etc. This confidential information would be shared only with appropriate staff members with the intent of making them aware of any potential problems that may arise while your child is in school. ___________ I give permission to share my childs medical information. ___________ I do not want to share my childs medical information. Student Name ________________________________________________ Parent/Guardian Signature _________________________________________________ Estimado Padre/Guardian: Una ley ha sido promulgada para proteger la privacidad de informacin de salud de todo estudiante. Para nosotros obedecer con (FERPA) Family Education Rights and Privacy Act, nosotros necesitamos permiso de los padres/guardianes para compartir informacin medica con los empleados apropiados de la escuela. Esta informacin medica puede incluir, pero no es limitada a, informacin sobre alergias, historial de asma, medicamentos, problemas de odos o de la vista, convulsiones o ataques, etc. Esta informacin confidencial ser compartida solamente con los empleados apropiados con la intencin de informarles de algn problema que pueda ocurrir mientras su hijo/a esta en la escuela. __________ Yo doy permiso para compartir informacin mdica de mi hijo/a. __________ Yo no doy permiso para compartir informacin mdica de mi hijo/a. Nombre del Estudiante ______________________________________________ Firma del Padre/Guardin ______________________________________________ Rev. 01/09
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TO BE COMPLETED BY PARENT
FRANKLIN TOWNSHIP PUBLIC SCHOOLS Health Appraisal Form
Name_________________________________________________________ M( ) F( ) Grade_______ Age_____ (Last) (First) (Middle) Address_______________________________________________________ Phone (______) _________________ DOB_________________________________ Place of Birth___________________________________________ (Month) (Day) (Year) Where is the student coming from? Within NJ ____________________________(which school in NJ) Out of State _________________(which state) Out of country ____________________ (which country) Fathers Name__________________________________ Employer/Phone________________________________ Mothers Name_________________________________ Employer/Phone_________________________________ Guardian_______________________________________Employer/Phone_________________________________ EMERGENCY CONTACT PERSON AND NUMBER________________________________________________ FAMILY PHYSICIAN/CLINIC_____________________________________ PHONE______________________ LANGUAGE SPOKEN AT HOME_______________________________________________________________
CHILDREN IN FAMILY Name DOB Name DOB _______________________________________________________________________________________________________ _______________________________________________________________________________________________________
HEALTH HISTORY DISEASE HISTORY TYPE/YEAR DISEASE HISTORY TYPE/YEAR Allergies Diabetes Drug Sensitivities Heart Disease Lyme Disease Otitis Media Hepatitis Rheumatic Fever Neuromuscular Disease Strep Infections Asthma Mononucleosis Chicken Pox Vision Disorder Convulsive Disorder Hearing Disorder ADHD Congenital Defects OPERATION/INJURIES (PLEASE SPECIFY): 1. 2. 3. MEDICATIONS:___________________________________________________________________________________________________________________________________________________________________________ ALLERGIES: Drug_________________________________________________________________________________________ Environmental_________________________________________________________________________________ Food_________________________________________________________________________________________ Speech Problems______________________________________________________________________________________ Date__________________________ Parent/Guardian Signature______________________________________
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FRANKLIN TOWNSHIP PUBLIC SCHOOLS
STUDENT HEALTH AND PHYSICAL EXAM FORM
TO BE COMPLETED BY FAMILY PHYSICIAN OR PEDIATRICIAN
Students Name: Birth Date:
Sex: Male Female
DISEASE HISTORY TYPE/YEAR DISEASE HISTORY TYPE/YEAR Allergies Diabetes Drug Sensitivities Heart Disease Lyme Disease Otitis Media Hepatitis Rheumatic Fever Neuromuscular Disease Strep Infections Asthma Mononucleosis Chicken Pox Vision Disorder Convulsive Disorder Hearing Disorder ADHD Congenital Defects OPERATION/INJURIES (PLEASE SPECIFY)
1. 2. 3. ADDITIONAL COMMENTS:
IMMUNIZATIONS:
Vaccine Type DISEASE DATE
1st Dose Mo/Day/Yr
2nd Dose Mo/Day/Yr
3rd Dose Mo/Day/Yr
4th Dose Mo/Day/Yr
5th Dose Mo/Day/Yr
6th Dose Mo/Day/Yr
DT(a)P/DT/Td OPV MMR Measles MCV PCV Hepatitis B Varicella Flu HIB Lead Level: Date of Last Lead Test: Mantoux (PPD) Date Administered Date read and Results: MEDICATIONS: ____________ ALLERGIES: Drug: Environmental: Food: ___________________
BOTH SIDES OF THIS FORM MUST BE COMPLETED
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TO BE COMPLETED BY FAMILY PHYSICIAN OR PEDIATRICIAN
FRANKLIN TOWNSHIP PUBLIC SCHOOLS Students Name: Exam Date: Height: Weight: Pulse: B/P: Vision: Uncorrected Right: Left: Vision: Corrected Right: Left: Hearing Screen: Right: Left: Normal Exam Abnormal Findings: Head Eyes Ears Nose Throat Lymph Glands Heart Lungs Abdomen Hernia Genitalia Skin Orthopedic Scoliosis Neurological Speech Nutrition Any limitation of activity? No Yes (please explain) Physicians signature: Date: Physicians Name, Address, and telephone number:
COMPLETE BOTH SIDES MM 11/06
PIC Registration Requirements online versionThe Registration Process
Registration Formhome language surveyemergency cardParents consent of records 2011Parent Information Center/Office of Student RegistrationPARENTS CONSENT FOR TRANSFER OF RECORDSParent Information Center/Office of Student Registration
residency affidavitNJ Family Care Health InsuranceIMM-combinedimm-19-memoIMM
nursing services formHealth appraisalFRANKLIN TOWNSHIP PUBLIC SCHOOLSCHILDREN IN FAMILY
Physical FormSTUDENT HEALTH AND PHYSICAL EXAM FORMTYPE/YEARDISEASE HISTORYFRANKLIN TOWNSHIP PUBLIC SCHOOLSCOMPLETE BOTH SIDES
AddressIDirecci6n: CityStateCiudadlEslado: Zip CodeC6digo Postal: Last Name Apellido_2: First NamelNombre: ReiationshipIRelaci6n: Address if different from abovelDireccion si es diferente: CityStatelCiudadlEstado: Zip CodeCodigo Postal: Last NameApellido: First NamelNombre_2: ReiationshipIRelaci6n_2: Address if different from aboveIDireccion si es diferente: CityStateCiudadlEstado: Zip CodeCodigo Postal_2: Last Name Apellido_3: First NamelNombre_3: SchooVEscuela: Last NameApellido_2: Last NameApellido_3: High School StudentslEstudiantes de Escuela Secundaria: If so what is the Name Cual es el nombre de la escuela: stateestado: que ano: Country 01 Dlrth: Grade: Last Name_2: First Name_2: Middle Name_2: Title: Address: City: State: Zip Code: Alt Telephone Ext: Birthdate optional: Employer: Work Address: City_2: State_2: Zip Code_2: Work Hours From To: 5:00 Email Address: Last Name_3: First Name_3: Middle Name_3: Title_2: Address_2: City_3: State_3: Zip Code_3: AIL Telephone Ext: B irthdate optional: Employer_2: Work Address_2: City_4: State_4: Zip Code_4: Work Telephone Ext_2: Email Address_2: First Contact: Telephone Ext: Relationship to Student: Address_3: City_5: State_5: Zip Code_5: Secondary Contact: Telephone Ext_2: Relationship to Student_2: Address_4: City_6: State_6: Zip code: Medical Alert 1: Medical Alert 2: Physician: Telephone Ext_3: Please Complete 1: Please Complete 2: Bus No: Phone number: If there is a legal separation in the family the school district requires legal documentation that indicates which of the parents: Previous Grade: The: 1974: Print Name of ParentGuardian: Grado Previo: El Distrito Escolar de: DIRECCIN DE ESCUELA PREVIA: PARENTS CURRENT ADDRESSDIRECCION DEL PADRE: OWNERS CURRENT ADDRESSDIRECCION ACTUAL DEL DUENO: RELATIONSHIP TO PARENTRELACION AL PADRE: I: the parent of: hereby affirm that I am residing with: at the following address: I hereby affirm that: are residing with me at: Name_2: Relationship: Address_7: Phone: undefined_5: Within NJ: which school in NJ Out of State: Out of country: Fathers Name: EmployerPhone: Mothers Name: EmployerPhone_2: Guardian: EMERGENCY CONTACT PERSON AND NUMBER: FAMILY PHYSICIANCLINIC: LANGUAGE SPOKEN AT HOME: Allergies: Diabetes: Drug Sensitivities: Heart Disease: Lyme Disease: Otitis Media: Hepatitis: Rheumatic Fever: Neuromuscular Disease: Strep Infections: Asthma: Mononucleosis: Chicken Pox: Vision Disorder: Convulsive Disorder: Hearing Disorder: ADHD: Congenital Defects: 1_2: 2_3: 3_3: MEDICATIONS 1: MEDICATIONS 2: Drug: Environmental: Food: Problems: Yes: SpecialEd No: Hispanic: NativeHawaiian: Asian: AmericanIndian: BlackOrAfricanAmerican: White: WorkPhone: CellPhone: EmergencyContactCheckBox: HighSchoolYes: HighSchoolNo: VocationalYes: VocationalNo: HomePhone: Email: ParentHomePhone: ParentWorkPhone: ParentCellPhone: ParentEmail: First NamelNombre_4: Sibling3FirstName: SchooVEscuela_2: Sibling3School: GenderFemale:
GenderMale:
unte ot tntry m u: SchoolEntryDateUS: Telephone: AltTelephoneExt: SurveyMother: SurveyFillFather: SurveyFillGrandpt: SurveyFillGuardian: SurveyFillOther: SurveyBeganEnglish: SurveyBeganSpanish: SurveyBeganGuj: SurveyBeganOther: SurveyFillOtherText: SurveyFamEnglish: SurveyFamSpanish: SurveyFamGuj: SurveyFamOther: SurveyBeganOtherText: SurveyMomEnglish: SurveyMomSpanish: SurveyMomGuj: SurveyMomOther: SurveyFamOtherText: SurveyDadEnglish: SurveyDadSpanish: SurveyDadGuj: SurveyDadOther: SurveyMomOtherText: SurveyDadOtherText: SurveyChild2momEnglish: SurveyChild2momSpanish: SurveyChild2momGuj: SurveyChild2momOther: SurveyChild2momOtherText: SurveyChild2DadEnglish: SurveyChild2DadSpanish: SurveyChild2DadGuj: SurveyChild2DadOther: SurveyChild2SiblingsEnglish: SurveyChild2SiblingsSpanish: SurveyChild2SiblingsGuj: SurveyChild2SiblingsOther: SurveyChild2DadOtherText: SurveyChild2FriendsEnglish: SurveyChild2FriendsSpanish: SurveyChild2FriendsGuj: SurveyChild2FriendsOther: SurveyChild2SiblingsOtherText: SurveyChild2FriendsOtherText: Work Telephone Ext: Work Hours From: Telephone_2: Telephone_2ext: SurveyEthnicityWhite: EmerMedInsNo: EmerFamCareYes: EmerFamCareNo: EmerMedInsYes: EmerCallMe: EmerNoCall: AffLastName2: AffLastName1: AfffirstName1: AfffirstName2: AffLastName3:
AffLastName4:
AffLastName5:
AffGender1: AffGender2: AffGender3: AffGender4: AffGender5: AffPhone1: AffPhone2: AffPhone3: AffPhone4: AffPhone5: AffParentLastName: AffParentFirstName: AffParentWorkPhone: AffParentCellPhone: AffOwnerFirstName: AffOwnerLastName: AffOwnerHomePhone: AffOwnerWorkPhone: AffOwnerCellPhone: AffParentHomePhone: NjiisNo: MedYes: MedNo: NjiisYesspan: NjiisYes: MedNoSpan: HAFGrade: HAFAge: EmployerPhone_3: HAFEmrPhone: HAFDRPhone: HAFName2: HAFDOB3: HAFDOB4: HAFName 1: HAFName 3: HAFName 4: SurveyEthnicityPI: SurveyEthnicityLat: SurveyEthnicityAsian: SurveyEthnicityBlack: SurveyEthnicityAI: LegalSeparationCheckBox: PreviousSchoolName1: PreviousSchoolName2: PreviousSchLoc1: PreviousSchLoc2: PreviousGrComp1: PreviousGrComp2: PreviousSchDate1: PreviousSchDate2: PreviousSchoolLangofInstruction1: PreviousSchoolLangofInstruction2: Text4: Last NameStudent:
MiddleNameStudent:
First NameStudent:
DateOfBirthStudent:
HAFDOB1: HAFDOB2: BirthPlace:
Address_5:
PhoneEXT: EmrWorkExt: WExt1: Work IloLlrsTo: Work IloLlrs From: Emerbuswalker: