Grade 1-5 Pre-Registration Form 2021

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Student Grade *

1-Student's Last Name *

2-Student's First Name *

2-Student's Middle Name

4-Date of Birth *

YYYY

5-Gender *

Male

Female

Prefer not to answer

3-Student ID

7-Parent/Guardian Name (Student resides with): *

8-Relationship: *

Parent’s Preferred Language of Communication (Written) *

6-Place of Birth of Student (country/city/state) *

8-Home/Native Language *

English

Other:

Required

9-Home Address *

10-Apt #

11-City *

12-State, Zip Code *

13-Home Phone Number

14-Cell Phone Number *

15-Email address *

16- 2nd Parent/Guardian Last Name

17- 2nd Parent/Guardian First Name

18-Phone number (2nd parent/guardian)

19-Name, City, State of Last School Student attended *

20-Last Grade Completed *

Pre-K

None

21-Health Insurance Information *

Private Health Insurance

Medicaid

Child Health Plus B

No Insurance

Required

22-If No Health Insurance, would you like to be contacted about getting coverage?

Yes

Clear selection

23-Health Alert; Any Health Condition that affects participation in physical activities? *

Yes

24-List any allergies your child has:

25-Special Education Information; does your child have an Individualized Education Plan (IEP)? *

Yes

26- Is the student Hispanic, Latino or of Spanish origin? (means a person of Cuban, Dominican, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, REGARDLESS race. *

Yes, Hispanic

No, not Hispanic

27- Mark all answers which apply to your child *

AMERICAN INDIAN OR ALASKAN NATIVE

ASIAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

BLACK

WHITE

Required

28- Housing Questionnaire: Where are you and your child(ren) currently living? *

In permanent housing

Double-Up: With another family or other person because of a loss of housing, economic hardship, or similar reason

In a shelter

In a hotel or motel

Other temporary living situation

29- Media & Photo Consent: I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of my child. I also grant to PS 201Q the right to edit, use, and reuse said products for nonprofit purposes including use in print, on the internet, and all other forms of media. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. *

Yes

Submit

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