Registration Appointment Scheduling Form

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Registration Appointment Scheduling Form_2023-2024

Please complete this form for each child you will be registering. If you have any questions, please email mainoffice@ps140q.org

Parent Full Name (First & Last Name) *

Parent Email Address *

Parent Phone Number *

Home Address (House Number and Street) *

Apartment

Town/City, State *

Zip Code *

Enrollment Status *

Zoned Student

Non-Zoned Student

Which grade will your child be registering for? *

Pre-K

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Student Full Name (First Name, Middle Name, Last Name) *

Student Date of Birth
*

YYYY

Sex of Student *

Male

Female

Prefer not to say

Does the student currently receive special education services? If yes, please specify services being received.

Does your child have an IEP (Individualized Educational Plan)? *

Yes

Unsure

Mother's First Name and Last Name (or Guardian) *

Mother's Cell Phone (or Guardian) *

Mother's Work Number *

Mother's Email Address *

What language does the mother prefer to receive communications in from the school? *

English

Spanish

Bengali

Urdu

Hindi

Chinese

Arabic

Haitain Creole

French

Spoken

Written

Does the child reside with the mother? *

Student lives with mother

Students DOES NOT live with mother

Father's First Name and Last Name (or Guardian) *

Father's Cell Phone (or Guardian) *

Father's Work Number *

Father's Email Address *

Does the child reside with the father? *

Student lives with father

Students DOES NOT live with father

What language does the father prefer to receive communications in from the school? *

English

Spanish

Bengali

Urdu

Hindi

Chinese

Arabic

Haitain Creole

Spoken

Written

Name of child's physician & clinic name *

Phone number of child's physician *

Does the child have any health condition that may affect participation in physical activities? *

Yes, my child has a health condition (please provide details in next question)

Please list any health conditions. *

Does your child have any allergies? *

Yes (List Allergies in next question)

List Allergies *

Insurance Coverage *

Private Health Insurance

Medicaid

No health insurance

Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Dominican, Mexican, Puerto Rican, Central or South America, or other Spanish culture or origin, regardless of race.

Federal law requires the New York City Department of Education to collect and record the ethnic identity and race of public school students. This information is used to determine funding for your school, among other things, and is kept safe and private. We need your help to accomplish this task. Please respond to the ethnicity and race identification questions on the back of this page. The first question gives you a chance to share if your child is of Hispanic, Latino, or Spanish origin. The second question gives you a chance to share your child’s race or races. The federal government provides the options that you will choose from. Please respond to both questions. We understand the sensitive nature of this process. The options may not represent a perfect or complete portrayal of your family’s own ethnic or race identification. We encourage you to select the options using your best judgment. If you choose not to answer, federal guidelines require New York City Department of Education school staff to respond on your behalf. Race and ethnicity information for students is protected by the confidentiality regulations. Thank you for your cooperation. *

Yes, Hispanic

No, not Hispanic

Select one or more races from the following five racial group
*

AMERICAN INDIAN OR ALASKAN NATIVE: original peoples of North America and and South America, including Central America

ASIAN: origins in the the Far East, Southeast Asia, or the Indian Sub-Continent Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: origins in Hawaii, Guam, or other Pacific Island

BLACK: origins in Black racial groups of Africa

WHITE: origins in Europe, North Africa, or the Middle East

Required

Housing Status

This form is intended to address the McKinney-Vento Act 42 U.S.C. 11435 and must be completed for each student. The information you provide is confidential. Your child will not be discriminated against based upon the information provided.

Doubled Up - With another family or other person because of loss of housing or as a result of economic hardship

Shelter - Emergency or transitional shelter

Hotel/Motel - Living in what is NOT an emergency or transitional shelter and involves payment

Other Temporary Living Situation - Trailer park, campground, car, park, public places, abandoned building, street, or any other inadequate living space

Permanent Housing - Student who is living in a fixed, regular, and adequate housing situation

Emergency Contact #1 (First and Last Name) *

Emergency Contact #1 Relationship *

Grandparent

Uncle/Aunt

Sibling

Family Friend

Emergency Contact #1 Phone Number *

Emergency Contact #2 (First and Last Name) *

Emergency Contact #2 Relationship *

Grandparent

Uncle/Aunt

Sibling

Family Friend

Emergency Contact #2 Phone Number *

Emergency Contact #3 (First and Last Name) *

Emergency Contact #3 Relationship *

Grandparent

Uncle/Aunt

Sibling

Family Friend

Emergency Contact #3 Phone Number *

Does your child have an active and current Order of Protection from anyone? If yes, you must provide us an updated and current copy on the date of registration. *

Yes

Does your child have siblings? If yes, please list their names and grades. *

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