Registering A New Scholar - Middletown City School District

The LEA should also ensure that the parent, person in parental relation, unaccompanied youth is aware that the student’shousing status will kept confidential and will only be shared with those LEA staff who are responsible for providingservices to the student and those responsible for keeping track of how many students are identified as living in temporaryhousing in the LEA.LEAs are advised to explain to parents that if a parent claims that her/her child is living in temporary housing, and theLEA wishes to conduct an investigation to verify this information, the LEA may conduct a home visit. However LEAscannot contact a landlord or building superintendent to verify a student’s housing status without prior parentalconsent. Contacting a landlord or building superintendent without the parent’s express prior written permission is aviolation of FERPA, a federal law.If the Parent, Person in Parental Relation, or Unaccompanied Youth Declines to Fill Out the HousingQuestionnaireIf the parent, person in parental relation, or unaccompanied youth declines to complete the Housing Questionnaire, theLEA should note on the form that the parent, person in parental relation, or unaccompanied youth declined to provide theinformation requested.Completing the FormIf a parent, person in parental relation, or unaccompanied youth enrolling in school indicates that a student is living in oneof the five temporary housing arrangements, the school may not require proof to verify where the student is living beforeenrolling the student. The five temporary housing arrangements are listed below:1. In a shelter,2. With another family or other person (sometimes referred to as “doubled-up”),3. In a hotel/motel,4. In a car, park, bus, train, or campsite, or5. Other temporary living situation.After the student is enrolled and attending classes, the school or LEA is permitted to verify the student’s housingarrangements. However, the student must first be enrolled in school. Again, LEAs cannot not contact a landlord orbuilding superintendent to verify a student’s housing status. (See above for more information.)Definitions of Temporary Housing Arrangements“With another family or other person” (also referred to as “doubled-up”)”LEAs should be aware that students who are sharing the housing of others are eligible for services under the McKinneyVento Act and State law, if sharing housing is due to loss of housing, economic hardship, or a similar reason.“Other temporary living situation”In addition to the four examples of temporary housing, students who lack a “fixed, adequate, and regular” nighttimeresidence are also covered as homeless under the McKinney-Vento Act and State law. This may include unaccompaniedyouth who have fled their homes or were forced to leave their homes and who do not otherwise meet the definition of“doubled-up.”“In permanent housing”Permanent housing means that the student’s living arrangements are “fixed, regular, and adequate.”Next Steps for LEAs with Students Living in Temporary Housing ArrangementsIf the parent, person in parental relation, or unaccompanied youth indicates that a student is living in temporaryhousing, the LEA must complete a Designation Form. If the LEA believes additional information is needed beforereaching a final decision on the student’s eligibility under McKinney-Vento, enrollment should not be delayed and aDesignation Form should still be filled out. For more information about determining eligibility see the National Center onHomeless Education’s Determining Eligibility Brief, available at: http://nche.ed.gov/downloads/briefs/det elig.pdf.If a student who is identified as homeless was last permanently housed in a different school district, the district ofattendance/local district will be eligible for tuition reimbursement from SED for the cost of educating the student. Schooldistricts should complete a STAC-202 form if eligible for tuition reimbursement. For more information about STAC-202forms contact the STAC Office at 518-474-7116 or NYS-TEACHS at 800-388-2014.Rev. 11/15/16

NOTE TO SCHOOLS/LEAS: Please assist students and families filling out this form. The form should be included atthe top page of registration materials that the district shares with families. Do not simply include this form in theregistration packet, because if the student qualifies as residing in temporary housing, the student is not required tosubmit proof of residency and other required documents that may be part of the registration packet.HOUSING QUESTIONNAIREName of LEA:MIDDLETOWN CITY SCHOOL DISTRICTName of School:Name of Student:LastGender: Male FemaleFirstDate of Address:(optional)Phone:The answer you give below will help the district determine what services you or your child may be able toreceive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act areentitled to immediate enrollment in school even if they don’t have the documents normally needed, suchas proof of residency, school records, immunization records, or birth certificate. Students who areprotected 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.)In a shelterWith another family or other person because of loss of housing or as a result of economic hardship(sometimes referred to as “doubled-up”)In a hotel/motelIn a car, park, bus, train, or campsiteOther temporary living situation (Please describe):In permanent housingPrint name of Parent, Guardian, orStudent (for unaccompanied homeless youth)Signature of Parent, Guardian, orStudent (for unaccompanied homeless youth)DateIf ANY box other than “In Permanent Housing” is checked, , then the student/family should be immediatelyreferred to the MV Liaison. In such cases, proof of residency and other documents normally needed forenrollment are not required and the student is to be immediately enrolled. After the student has beenenrolled, the district/school must contact the previous district/school attended to request the student'seducational records, including immunization records, and the enrolling district's LEA liaison must help thestudent get any other necessary documents or immunizations.NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that aDesignation Form is completed.Rev. 11/15/16

ENLARGED CITY SCHOOL DISTRICT OF MIDDLETOWN TRANSMITTAL FORMFOR OFFICE USE ONLYStudent ID Number New ReturningReferred to: Bilingual/ESL Special Services MAPSSchoolEnrollment DateBus #TimeBus #TimeGradeComing fromStart dateLocation of pick up (a.m.)Location of drop off (p.m.) Proof of Age Immunization Records Proof of Residence Proof of Custody/Guardianship DS2999REGISTRATION FORMStudent’s Last NameFirstMiddle Male FemaleDate of BirthResidence AddressCity/State/ZipMailing AddressCity/State/ZipSTATE REQUIRED INFORMATION Yes, Hispanic No, Non-HispanicPrimary Language spoken at Home:Race (please choose one or more): American Indian or Alaskan Native Black or African American Asian WhiteIs the parent on active duty in the Armed Forces? Native Hawaiian or Other Pacific Islander Yes NoDates Active: From:To:PARENT/GUARDIAN INFORMATIONMother/Guardian/Foster Parent Full NameAddress (if different from student)Home Phone ()Work Phone (Email (Please print clearly)Father/Guardian/Foster Parent Full NameAddress (if different from student)Home Phone ()Email (Please print clearly)D.O.B.)Cell Phone()@D.O.B.Work Phone ()Cell Phone (@)Turn Over 493940.1 6/2018

List Other Children in DistrictNameGenderDOBGradeParent/Legal Guardian SignaturePresent SchoolDateCentral Registration Office 53 Bedford Ave Middletown, NY 10940Telephone (845) 326-1300 Fax (845) 326-1321Email: www.middletowncityschools.org493940.1 6/2018

STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234Office of P-12Lissette Colón-Collins, Assistant CommissionerOffice of Bilingual Education and World Languages55 Hanson Place, Room 594Brooklyn, New York 11217Tel: (718) 722-2445 / Fax: (718) 722-245989 Washington Avenue, Room 528EBAlbany, New York 12234(518) 474-8775 / Fax: (518) 474-7948Home Language Questionnaire (HLQ)Please write clearly when completing this section.Dear Parent or Guardian:In order to provide your child with thebest possible education, we need todetermine how well he or sheunderstands, speaks, reads and writesin English, as well as prior school andpersonal history. Please complete thesections below entitled LanguageBackground and Educational History.Your assistance in answering thesequestions is greatly appreciated.Thank you.STUDENT NAME:FirstMiddleLastDATE OF BIRTH:MonthGENDER:Day Male FemaleYearPARENT/PERSON IN PARENTAL RELATION INFO:Last NameFirst NameRelation toStudentHOME LANGUAGE CODELanguage Background(Please check all that apply.)1. What language(s) is(are) spoken in the student’s home English Otheror residence?specify2. What was the first language your child learned? English3. What is the Home Language of each parent/guardian? Mother Otherspecify Fatherspecifyspecify Guardian(s)specify4. What language(s) does your child understand? English Other5. What language(s) does your child speak? English Other6. What language(s) does your child read? English Otherspecify Does not speakspecify Does not readspecify7. What language(s) does your child write? English Other Does not writespecifyTHIS SECTION TO BE COMPLETED BY DISTRICT IN WHICH STUDENT IS REGISTERED:STUDENT ID NUMBER IN NYS STUDENTINFORMATION SYSTEM:SCHOOL DISTRICT INFORMATION:District Name (Number) & SchoolAddress1ENGLISH

Home Language Questionnaire (HLQ)—Page TwoEducational History8. Indicate the total number of years that your child has been enrolled in school9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write inEnglish or any other language? If yes, please describe them.Yes* No Not sure *If yes, please explain:How severe do you think these difficulties are? Minor Somewhat severe Very severe10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received:.Age at which services received (Please check all that apply): Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)10c. Does your child have an Individualized Education Program (IEP)? No Yes11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)12. In what language(s) would you like to receive information from the school?Month:Day:Signature of Parent or of Person in Parental RelationYear:DateRelationship to student: Mother Father Other:OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQNAME:POSITION:IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEWNAME:POSITION:ORAL INTERVIEW NECESSARY: NO YES**DATE OF INDIVIDUALINTERVIEW:MODAYYR.OUTCOME OFINDIVIDUALINTERVIEW: ADMINISTER NYSITELL ENGLISH PROFICIENT REFER TO LANGUAGE PROFICIENCY TEAMNAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELLNAME:POSITION:PROFICIENCY LEVELACHIEVED ONNYSITELL:DATE OF NYSITELLADMINISTRATION:MO.DAY ENTERING EMERGING TRANSITIONING EXPANDING COMMANDINGYR.FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:2ENGLISH

NEW YORK STATE MIGRANT EDUCATION PROGRAMIDENTIFICATION & RECRUITMENT OFFICEPARENT SURVEYThe Migrant Education Program (MEP) is authorized by Title I, Part C of theEvery Student Succeeds Act (ESSA). The MEP provides a variety of educational services to familieswho work in agriculture, regardless of their nationality or legal status. This program is free ofcharge to all eligible families and may include tutoring, free lunch eligibility, educational field trips,summer programs, parent involvement activities, emergency needs and referrals to other services asneeded.Please take few minutes to complete this questionnaire.Have you or has someone in your family worked on a farm?Have you moved during the past three years? Any agricultural, farm, or fishing work (such as hay, dairy, fruit or vegetablecrops, poultry, fishing, nursery/greenhouse, etc.) Work related to logging, harvesting, or initial processing of trees. Work at a food processing plant, (such as meat or poultry processing plants,packing fruits or vegetables, etc.)If you answer YES, please provide your contact information below:Parent/Guardian Name:Home address:Telephone number: ( )- - Best time to be reached: AM/PMPrevious Address:Student name: Age GradeStudent name: Age GradeTo submit this referral please fax to 845-257-2953 or mail to Mid-Hudson Migrant Education Program353 VH Annex 1 Hawk Drive New Paltz, NY 12561

Enlarged City School District of Middletown, New YorkNEW ENTRANT REGISTRATIONDisability QuestionnaireStudent:Date of Birth:Date:(Official Use Only)Grade:Home School:Parents/Legal Guardian:Address:Phone:Cell:Email:Has this student been identified by the Committee on Special Education as a student with a disability?Yes No If no, is this student suspected of having a disability? Yes No Is this student in a Day Treatment or Residential Facility? Yes No If yes, where?Are there other children in the household under the age of 21 who are disabled or are suspected of havingdisability? Yes No If yes, please complete the following pensatory Education/ Supplemental InstructionHas this student ever attended Middletown Schools? Yes No Dates:Please indicate if this student is receiving extra help in:ReadingSpeechYes NoYes No MathYes No Writing Yes No OtherDo you feel this student needs additional help? Yes No If yes, reason:This information will be kept confidential and will be forwarded directly to the Special Services DepartmentRevised 11/9/16

REQUEST OF STUDENT RECORDSFOR OFFICE USE ONLYPrevious School AddressFor Office Use OnlyTelephone: ()fax (For placement, please fax 845-326-1321 oremail the following: Proof of Age Immunization Record Report Card Transcript/Disciplinary Records IEP (Individualized Education Program))Start Date:Please be advised that the following child who attended your school has transferred to the Enlarged CitySchool District of Middletown, New York:Student's Name:Date of Birth:Grade:Please forward all scholastic records, transcript/report card, test scores (i.e., Terra Nova, ELA, Math,NYSESLAT, NYSITELL), health records, birth certificate or other proof of age, disciplinary records andany other pertinent information concerning this child to: Maple Hill Elementary School (Grades K-5) 491 County Route 78, Middletown, NY 10940Main Office: 845-326-1740 Fax: 845-326-1795 Nurse Office: 845-326-1735 Fax: 845-326-1796 Maple Hill Elementary School Annex at Truman Moon (Grades K-5) 53 Bedford Ave,Middletown, NY 10940Main Office: 845-326-1780 Fax: 845-326-1788 Nurse Office: 845-326-1860 Fax: 845-326-1775 Presidential Park Elementary School (Grades K-5) 50 Roosevelt Avenue, Middletown, NY10940Main Office: 845-326-1850 Fax: 845-326-1851 Nurse Office: 845-326-1860 Fax: 845-326-1862 William A. Carter Elementary School (Grades K-5) 435 East Main Street, Middletown, NY10940Main Office: 845-326-1711 Fax: 845-326-1723 Nurse Office: 845-326-1714 Fax: 845-326-1724 Monhagen Middle School (Grades 6-8) 555 County Route 78, Middletown, NY 10940Guidance: 845-326-1764 Fax: 845-326-1758 Nurse Office: 845-326-1676 Fax: 845-326-1675 Twin Towers Middle School (Grades 6 -8) 112 Grand Ave, Middletown, NY 10940Guidance: 845-326-1648 Fax: 845-326-1644 Nurse Office: 845-326-1638 Fax: 845-326-1636Middletown High School (Grades 9-12) 24 Gardner Avenue Extension, Middletown, NY 10940 MainOffice: 845-326-1530 Fax: 845-326-1605 Nurse Office: 845-326-1590 Fax: 845-326-1606 House 1 845-326-1536 Fax: 845-326-1621House 2 845-326-1541 Fax: 845-326-1622 House 3 845-326-1546 Fax: 845-326-1623 House 4 845-326-1552 Fax: 845-326-1624Thank you for your consideration in this matter. Any questions, please contact Central Registration at845-326-1300 Fax 845-326-1321I hereby authorize the release of all the above named records:Signature of Parent or GuardianDate493936.1 6/2018

ENLARGED CITY SCHOOL DISTRICT OF MIDDLETOWNEMERGENCY/EARLY RELEASE INFORMATION FORMStudentGrade:School:School Year:Teacher or Home Room:PLEASE COMPLETE ALL 4 SECTIONS BELOW OF THIS EMERGENCY FORMSECTION 1EMERGENCY/EARLY RELEASE INFORMATIONIf my child must leave school prior to the end of the school day due to a medical appointmentor other personal business matter, the following individuals are authorized to sign him/her out.Additionally, these individuals may be called if the school should need to contact someoneduring an emergency or in the event of an emergency dismissal prior to the end of the regularlyscheduled school day.PLEASE LIST CONTACT PERSONS IN THE ORDER YOU WOULD LIKE THEM TO BE CALLED#1 NameHome PhoneCircle One: Parent/Guardian/Other Work Phone#2 NameHome PhoneCircle One: Parent/Guardian/Other Work Phone#3 NameCell PhoneHome PhoneCircle One: Parent/Guardian/Other Work Phone#4 NameCell PhoneHome PhoneCircle One: Parent/Guardian/Other Work PhoneSECTION 2Cell PhoneCell PhoneEARLY RELEASE PROCEDURES1. The parent, guardian or other contact person must report to the main office to sign outa student.2. The person signing out a student must provide a valid form of identification providingthey are listed as a contact person.3. The person signing out a student must provide a signed excuse letter to the main office.4. The person signing out a student must fill in the appropriate blocks in the schoolsStudent Sign Out Log.

SECTION 3EMERGENCY INSTRUCTIONS FROM PARENTIn the event of an emergency school or district wide dismissal, my child has been instructed todo the following: (Check One)GO HOME. My child can let himself/herself in the home or if my child arrives home andno one is there, my child should walk to the following address:Resident’s Name/Relationship to ChildAddressPhone NumberDO NOT GO HOME. My child will go directly to the following address. (Within schoolattendance area):Resident’s Name/Relationship to ChildAddressPhone NumberNOTE: Children at the elementary school level will not be released unless contact with a parent,guardian or emergency contact person has been made.SECTION 4FAMILY CODEParents or guardians may make a temporary change to the persons listed in BLOCK 1 of thisform by contacting the schools main office. You must provide us, on the line below, with yourown identification number or code name in order to make these changes. Any long term orpermanent changes must be done in writing and should also reference this code. This codeshould be safeguarded to avoid unauthorized changes to this form. YOU WILL RECEIVE ONE OFTHESE FORMS FROM EACH SCHOOL THAT YOUR CHILDREN ATTEND. PLEASE COMPLETE ANDRETURN THE FORMS TO EACH SCHOOL. USE THE SAME CODE FOR ALL OF YOUR CHILDRENATTENDING SCHOOL IN THE DISTRICT.I have selected the following identification number or code name:Parent or Guardian Signature:Date:SCHOOL USE ONLY:COPY DISTRIBUTIONMAIN OFFICEMEDICAL OFFICEEMERGENCY FILE

20083110R1 of 2Community RelationsSUBJECT: MEDIA ACCESS: STUDENT INTERVIEWS, PHOTOGRAPHSAND VIDEOTAPESThese regulations apply to all representatives of news media agencies and govern media access tostudents during instructional hours and/or school activities whether occurring on or off school grounds.These regulations do not apply to general media coverage of any events of public interest (such as anathletic event, lecture, school play, Board meetings, and the like) regardless of the time and location ofsuch public interest events.AuthorizationAll media representatives must report to the Main Office of the building to which access is requestedin order to obtain authorization from the Building Principal or his/her designee for access to the buildingand/or to interview photograph, or videotape District students.Parental/guardian consent must be obtained prior to granting the media permission to interviewstudents, or prior to the taking of photographs and/or videotapes (as well as subsequent publication)which would identify individual students or groups of students. ln such instances, parents/guardianswill be advised of the use and ultimate disposition of the interview, photograph and/or videotape toassist them in making their decision.No special permission shall be required from media representatives prior to the publishing of newsarticles, taking of photographs and/or videotapes of general school events which are of public interest asnoted above.Prior to granting media access to individual students, the Principal or his/her designee shall beapprised o f all information including, but not limited to, the date, location, purpose, and length ofaccess time requested by the media representative. Where permission is granted. media

school within our district. Thank you for your attention in this matter. To register a scholar, you will need to bring the following with you to the Registration Office: Parent/Guardian/Person in Parental Relation – Photo ID Required! Proof of Age –Scholar’sA copy of the Scholar’soriginal b