SCRANTON SCHOOL DISTRICT PK - 12 STUDENT REGISTRATION APPLICATION STUDENT INFORMATION

NAME: GENDER: Male Female

LAST FIRST MIDDLE

HISPANIC/LATINO: Yes No RACE (circle all that apply): American Indian/Alaska Native Asian

Black/African American

Native Hawaiian/Other Pacific Islander White

DOB: CITY OF BIRTH:

STATE OF BIRTH: COUNTRY OF BIRTH:

DATE OF PA ENTRY: DATE OF US ENTRY : GR 09 ENTRY DATE:

IMMIGRANT: HOME LANGUAGE:

REPEATING LAST YEAR: Yes No

PRESENT ADDRESS: HOME PHONE: Street City State Zip

PREVIOUS HOME ADDRESS:

WITHDRAW DATE: WITHDRAW GRADE:

PREVIOUS SCHOOL:

PREV. SCHOOL ADDRESS:

PARENT/GUARDIAN INFORMATION

STATUS (Circle One): SINGLE

MARRIED SEPARATED 2

DIVORCED 2 GUARDIAN 2 FOSTER 3

RELATIONSHIP: MAIDEN NAME:

PHONE (H): (C):

EMPLOYER: PHONE (W):

RELATIONSHIP: SPOUSE:

PHONE (H): (C):

PARENT/GUARDIAN 1:

ADDRESS SAME AS ABOVE: -or- ADDRESS (H):

EMAIL:

PARENT/GUARDIAN 2:

ADDRESS SAME AS ABOVE: -or- ADDRESS (H):

EMAIL: EMPLOYER: PHONE (W):

ADDITIONAL SCHOOL-AGE CHILDREN

NAME SCHOOL AGE GRADE

Date

Utility Bill(s)

OFFICE USE ONLY Affidavit of Res 1302 Affidavit

Custody Decree 2

Foster – Court Letter 3

Parent Sworn Statement 1304 Immunization Birth Certificate Special Ed./504 Verif.1

Language Survey Proof of Residency(2): PA Driver’s License or PA Photo ID

Bank Statement Employer/Pay

PA Vehicle Registration/Ins Health Insurance

Academic Yr: Grade: Bldg:

1st Day of Enrollment: Counselor: SSD Student ID:

PA Secure ID:

Sworn Statement

SCHOOL YEAR__2018________ BUILDING __________ GRADE __________

Parent/Guardian Signature

Registered By Date

Special Ed Signature________________________________ Date

SPECIAL ED: Yes No MIGRANT: Yes No

Full-time Active Military: Yes No

Revised 5/2016

 SCRANTON SCHOOL DISTRICT 425 North Washington Avenue

Scranton PA18503 Phone 570-348-3474

Fax 570-348-2570

PARENTAL REGISTRATION SWORN STATEMENT Pennsylvania School Code § 13-1304-A states in part “Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.”

Please complete the following:

I hereby swear or affirm that my child (check one) □was/□was not previously suspended or expelled, or (check one) □is/□is not presentlysuspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property. I make this statement subject to the penalties of 24 P.S. § 13-1304-A (b) and 18 Pa. C.S.A. § 4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief. If this student has been or is presently suspended or expelled from another school, please complete the following:

Name of the school from which student was suspended or expelled _____________________________________

Dates of suspension or expulsion _________________________________________________________________

Reason for suspension/expulsion (optional) _________________________________________________________

Please provide additional schools and dates of expulsion or suspension

School: __________________________________________________________ Date: _________________________

School: __________________________________________________________ Date: _________________________

I ASSERT THAT THE FACTS SET FORTH HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. I UNDERSTAND THAT IT IS A SUMMARY CRIMINAL OFFENSE TO KNOWINGLY PROVIDE FALSE INFORMATION IN THIS SWORN STATEMENT FOR THE PURPOSE OF ENROLLING A CHILD IN THE DISTRICT’S SCHOOL, AND THAT THE PENALTY FOR SUCH AN OFFENSE IS A FINE OF NOT MORE THAN THREE HUNDRED DOLLARS ($300), OR 240 HOURS OF COMMUNITY SERVICE, OR BOTH, IN ADDITION TO PAYMENT OF THE DISTRICT’S COURT COSTS AND TUITION FEES.

I further certify that I will notify the Scranton School District immediately in the event that the facts set forth herein shall no longer be correct or shall change. I also certify that I will cooperate with and be responsive to request for information or investigation concerning the continuing validity of this sworn statement.

I, the resident, have read and understand the contents of this document and have received of copy for my keeping. I have received a copy of the Pennsylvania school immunization requirements and required documents for application for registration for school attendance in Pennsylvania. I understand that my child will not be officially enrolled in the Scranton School District until all completed required documents have been approved by the school authorities. Through my signature, I grant the school district permission to investigate the above information that I have presented in this sworn statement for confirmation and factual accuracy.

Date: _________________________ __________________________________________ Parent/Guardian Signature

Revised 5/2016

  SCRANTON SCHOOL DISTRICT 425 North Washington Avenue

Scranton, PA 18503 Student Services

Phone 570-348-3474

Fax 570-348-2570

Special Education Phone570-348-3695 Phone 570-348-3471 Fax 570-348-3156

John Adams Elementary School 927 Capouse Ave. Scranton PA 18509 Phone 570-348-3655 Fax 570-348-3163

Neil Armstrong Elementary School N. Lincoln Ave. & Clearview St. Scranton PA 18508 Phone 570-348-3661 Fax 570-348-3599

George Bancroft Elementary School 1002 Albright Ave. Scranton PA 18508 Phone 570-348-3667 Fax 570-348-3376

John F. Kennedy Elementary School Prospect Ave. & Saginaw St. Scranton PA 18505 Phone 570-348-3673 Fax 570-558-8972

William Prescott Elementary School Prescott Ave. & Myrtle St. Scranton PA 18510 Phone 570-348-3683 Fax 570-348-3167

McNichols Plaza Elementary School 1111 South Irving Ave. Scranton PA 18505 Phone 570-348-3685 Fax 570-348-3499

Robert Morris Elementary School 1824 Boulevard Ave. Scranton PA 18509 Phone 570-348-3681 Fax 570-348-3160

Charles Sumner Elementary School N. Sumner Ave. & Swetland St. Scranton PA 18504 Phone 570-348-3688 Fax 570-348-3370

Isaac Tripp Elementary School 1000 North Everett Ave. Scranton PA 18504 Phone 570-558-2700 Fax 570-558-2707

John G. Whittier Elementary School 700 Orchard St. Scranton PA 18505 Phone 570-348-3690 Fax 570-348-3674 Whittier Annex: 4th/5th Grade Center 638 Hemlock St.Scranton, PA 18505 Phone 570-207-1427 Fax 570-207-3413

Francis Willard Elementary School 1100 Eynon St. Scranton PA 18504 Phone 570-348-3692 Fax 570-348-1861

Electric City Academy(Monticello and Lincoln Jackson Academy)1739 Dickson Ave.Scranton, PA 18509Phone 570-558-2728Fax 570-207-1271

Northeast Intermediate School 721 Adams Ave. Scranton PA 18510 Phone 570-348-3652 Fax 570-963-3301

South Scranton Intermediate School 355 Maple St. Scranton PA 18505 Phone 570-348-3634 Fax 570-340-6675

West Scranton Intermediate School 1401 Fellows St. Scranton PA 18504 Phone 570-348-3475 Fax 570-348-3610

Scranton High School 63 Mike Munchak Way Scranton PA 18508 Phone 570-348-3481 Fax 570-348-3487

West Scranton High School 1201 Luzerne St. Scranton PA 18504 Phone 570-348-3625 Fax 570-348-3622

CONSENT FOR RELEASE OF STUDENT RECORDS Student Information Student Name:_________________________________________________ Grade:____________ Name of Last School Attended:__________________________________________________________ Address:____________________________________________________________________________ ____________________________________________________________________________________ Telephone Number:___________________________ Fax Number:_________________________

Failure to provide the above information may delay enrollment. Information Requested Scranton School District may have a copy of or access to ALL of the following school records for the above named student:

Academic Records

Special Education RecordsDiscipline Records

Medical Records

_________________

Date Please forward records to the above circled building.

________________________________ Parent/Guardian Signature

Nurse Signature: __________________________________________  Date: _____________________ 

Revised 5/2016

SCRANTON SCHOOL DISTRICT 425 North Washington Avenue

Scranton PA 18503 Phone 570-348-3474

STUDENT HEALTH STATUS

___________________________________________ _____________ ________________ Student’s Name Grade School Year

❏ Please check here if your child has no existing health condition. ❏ Please check here if your child wears glasses or contacts.

Please check the appropriate box if your child’s physician has diagnosed him/her with any of the following conditions: ❏ Arthritis ❏ Asthma ____________________________________________________________ ❏ Attention Deficit Disorder (ADD, ADHD) _______________________________________________ ❏ Bleeding Disorder ❏ Surgery in the last 12 months: List: __________________________________ ❏ Diabetes _____________________________ ❏ Other Health Conditions:_____________________ ❏ Seizure/Epilepsy (last seizure was ______________) ❏ Takes prescription medications * (name and dosage of medication) Reason for taking medication: ____________________________________________________________________________________ ____________________________________________________________________________________ Please explain medical condition for which medication is required: ____________________________________________________________________________________ ____________________________________________________________________________________ *When medications are to be given to your child at school, a Scranton School District Medication Administration Consent Form must be completed by parent/guardian and Primary Care Physician.

❏ No ❏ Yes Does your child have severe or life-threatening allergies?

(If yes, please check the appropriate box(s) and list.)

❏ Food Allergy: ❏ Medication Allergy: ❏ Insect (Bite/Sting) Allergy: ❏ Other: ______________________________________________________________________ ❏ No ❏ Yes Does your child have an Epi-pen? **When an Epi-pen is required, a Scranton School District Medication Administration Consent Form must be completed and an Epi-pen sent to school.

__________________________________________________ ______________________ PARENT/GUARDIAN SIGNATURE DATE

SCRANTON SCHOOL DISTRICT NURSE ONLY (Kindergarten Only): Visual Acuity: FAR VISION NEAR VISION

Right  Left  Right  Left 

With glasses/contacts

Without glasses/contacts

Referral Made       □YES □NO

Hearing Acuity: 

Right   Left 

Decibel/Frequency

Referral Made       □YES □NO

Fax 570-348-2570

Revised 5/2016

SCRANTON SCHOOL DISTRICT 425 North Washington Avenue

Scranton PA 18503 Phone

570-348-3474 Fax 570-348-2570

SCRANTON SCHOOL DISTRICT PHYSICAL FORM

It is required by State Law that all students upon initial school entry K/1, grades 6, and grades 11 have a physical examination on file as part of the student school health record. If a student transfers into the Scranton School District Title 28 Chapter 23 (23.2) of Pennsylvania School Code states that if no physical is on file that a medical examination, regardless of age or grade will be required.

All students upon initial school entry K/1, grades 6, and grades 11 must have this form completed and returned to their respective school nurse:

Student Name:________________________________ Birthdate:_____________________

Please note any Medical Concerns: ___________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________ 

Varicella Vaccine is also a requirement:

Student had chicken pox: yes or no _____________ Date:____________________

Student had vaccine: yes or no _____________ Date:____________________

Choose and Sign:________ I give my consent for my child to be examined by the school physician (this will include a hernia check for all

male students).

______________________________________ _________________________ (Signature) (Date)

I would like to be present for the exam: yes or no (circle)

________ I will have my Private Physician complete the Physical Form and return it to the Medical Room.

______________________________________ _________________________ (Signature) (Date)

Students who fail to submit proof of the required immunizations within the 8 months provisional period shall be barred from attending school. A student who does not have proper proof of immunizations will receive a "Notice of Exclusion from School" signed by the principal excluding the student. The student will then remain out of school until such time as the student provides proof of having had the medically appropriate immunizations as required. During the child's exclusion from school for noncompliance, the child's parents or legal guardian shall be considered in violation of compulsory attendance requirements set out in The Pennsylvania School Code.

Revised 5/2016

SCRANTON SCHOOL DISTRICT 425 North Washington Avenue

Scranton PA 18503

Phone 570-348-3474 Fax 570-348-2570

FAMILY SURVEY

Date:______________________

Parent/Guardian:_______________________________________________________________

Address:______________________________________________________________________

Home Phone:______________________________

Children’s names:__________________________ Grade: Elementary Middle High

Children’s names:__________________________ Grade: Elementary Middle High

Children’s names:__________________________ Grade: Elementary Middle High

Have you or any member of your household worked or looked for work in any of the following agricultural activities during the last 3 years? Please check all that apply.

_____Farming (Dairy, Veal, Horse, Poultry) _____Food processing plant (Milk, Beef, Pork, Poultry)

_____Logging (Cutting, Trimming) _____Christmas Tree Farm or Nursery

_____Vegetables or Fruit Farming _____Crop Farming

What type of work are you doing now?______________________________________________

Your child may qualify for an educational program, which includes free year-round educational support as well as receiving books from the Reading Is Fundamental (RIF) Program. Someone will be contacting you to determine if your child is eligible for this program.

All responses are confidential and will be used solely for educational purposes.

Central Susquehanna Intermediate Unit, Northeast Migrant Education Program P.O. Box 213, Lewisburg, PA 17837

Official Use Only – Family Contact Log

Revised 5/2016

Federal Law 99.21 “No parent signature required for educational records sent to another educational agency”.

SCRANTON SCHOOL DISTRICT 425 North Washington Avenue

Scranton PA 18503 Phone 570-348-3474

Fax 570-348-2570

HOME LANGUAGE SURVEY

The Office of Civil Rights (OCR) requires that school districts identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identification.

Student Name _____________________ _______ ____________________________ Grade ________ First Name MI Last Name

Guardian Name ____________________ _______ ____________________________ First Name MI Last Name

Address____________________________________________ ___________________________ _____________ Street City State Zip

Phone Number_________________________ __________________________ __________________________ Home Work Cell

1. Was your child born in the United States? □ Yes □ NoIf yes, in which state? _____________________ If no, in what other country? _____________________ Date of U.S. Entry:____________

2. What is the language most frequently spoken at home? _____________________________________________3. If available, in what language would you prefer to receive communication from the school? _____________________________4. Is your child’s first learned or home language anything other than English? □ Yes □ No

If you responded “YES” to question number 4 above, please answer the following questions:

5. In what country did your child most recently reside? ______________________________________________6. Which language did your child learn when he/she first began to talk? _________________________________7. What language does your child most frequently speak at home? _____________________________________8. What language do you most frequently speak to your child? (Father) ________________________________

(Mother) _________________________________

9. Please describe the language understood by your child (check only one):A. □ Understands only the home language and no English?B. □ Understands mostly home language and some English?C. □ Understands the home language and English equally?D. □ Understands only English?

Parent/Guardian Signature: _______________________________ Date: ____________________

*The school district has the responsibility under the federal law to serve students who are limited English proficient and need English instructionalservices. Given this responsibility, the school district has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district may conduct screenings or ask for related information about students who are already enrolled in the school as well as students who enroll in the school district in the future.

OFFICE USE ONLY

ESL Services Yes ____ No ____ ESL Classes Yes ____ No ____ Proficiency Level _____________ Level ___________________ Testing Date _________________ Entry Date ___________________ Comments ______________________________________ ESL Staff _____________________________________