East Haddam Public Schools Student Registration Form Section I - Student Information Today’s Date: / / Last: Entering Grade: Formal Name (Please enter name from First: Entering Date: Birth Certificate unless legally changed) Full Middle: Preferred Name: Is preferred name used on all school documents? Y N Suffix (i.e. Jr., II): Mailing Address: (if different) Student Address: Street: (No PO Boxes) City: State: Zip: ( ) If you do not have a residence phone, Home Phone: (Required) please enter primary contact’s cell number. LOCKER#/COMBO: TEACHER/HOMEROOM: School use only: [ ] Male [ ] Female Gender Month: Day: Year: Date of Birth Staff initials: City: State: Country: Birth Place [ ] Yes [ ] No [ ] Choose not to answer (check yes if student was not born in the U.S. and Immigration has NOT attended school in any state for more than three (3) years.) Status Hispanic/Latino? [ ] Yes [ ] No [ ] Am. Indian or [ ] Asian [ ] Black or African [ ] Native Hawaiian or [ ] White Race (check all Alaska Native Am. Other Pacific Islander that apply) Child’s first language: Is child limited English proficient? Primary What language is spoken at home: Language Student lives with …. [ ] Mother/Father [ ] Mother Only [ ] Father Only Check ONE [ ] Guardian [ ] Mother/Stepfather [ ] Father/Stepmother [ ] Other:__________ [ ] Mother/Mother [ ] Father/Father [ ] Joint Custody [ ] Mother Deceased? [ ] Father Deceased? (court documentation required) Custody Alert: List all siblings’ names and grades:

Homeless: [ ] Yes [ ] No Check yes if student lacks a fixed regular and adequate nighttime residence. Section II - Transfer Information Name of Sending School: City: Last Grade Completed: Exit Date: Has student previously attended school in East Haddam? [ ] Yes – When? Has student previously attended a Pre-School or Headstart Program? [ ] Yes – Where?

State: [ ] No [ ] No

Section III – Parent/Guardian Information- **Living with Student Legal Relationship: [ ] Mother [ ] Father [ ] Other: Name #1: Phone: Cell Phone: Email: Employer: Work Phone: Work Email Is this parent/guardian active Military? [ ] yes [ ] no What Branch? Name #2 | Legal Relationship: [ ] Mother [ ] Father [ ] Other: Phone: | Cell Phone: Email Employer | Work Phone Work Email Is this parent/guardian active Military? [ ] yes [ ] no What Branch? OVER PLEASE

Section IV – Parent/Guardian-2 Information – **NOT Living with Student or Joint Custody Home Does the student reside in this home as a joint custody residence? [ ] Yes [ ] No Legal Relationship: [ ] Mother [ ] Father [ ] Other: Name #1: Mailing Address: Street Address: Home Phone: Cell Phone: Home Email: Employer: Work Phone: Work Email: Name #2: | Relationship: [ ] Mother [ ] Father [ ] Other: Cell Phone: Employer: | Work Phone: Are either of these parents/guardians active Military? [ ] yes [ ] no Which One? What Branch? Will this parent/guardian be receiving second mailings of the student’s records/information? [ ] Yes [ ] No Section V - Emergency Information (*Please list alternate contacts, other than parents/guardians) Medical Practice’s Name: Phone: Does student have medical insurance? [ ] Yes [ ] No Preferred Doctor’s Name: *Name of Emergency Contact #1: Contact #1 Phone: *Name of Emergency Contact #2: Contact #2 Phone: *Name of Emergency Contact #3: Contact #3 Phone: EVERBRIDGE INFORMATION The school district employs an automatic phone dialing and email sending service called Everbridge. The system will be used in the event of an emergency and to notify families of important school information including school closings or delayed openings.

Forms of Communication TEXT Phone 1 TEXT Phone 2 Primary Email Primary Phone Alt. Phone 1 Alt. Phone 2 Alt. Email 1 Alt. Email 2 Work Phone 1 Extension: Work Phone 2 Extension: Everbridge has the ability to contact a secondary parent/guardian in the case of Joint Custody. Please indicate numbers below for Secondary Alerts only if needed. TEXT Phone 1 TEXT Phone 2 Email Phone PROOF OF RESIDENCY An affidavit of Residency may be required

In order for student registration to be complete, documents showing the street address where the student resides must be submitted with this form. Either: [ ] Mortgage Statement or [ ] Lease Agreement or [ ] Real Estate Bill And (1):

[ ] Utility Bill

[ ] Phone Bill [ ] Driver’s License [ ] Personal Property Tax Bill

Staff Initials:____________ COPY TO: Superintendent Assistant

Revised 7/2017