Please have the following documents ready (if you submit the form without them a registrar will reach out to obtain them)

• A certified original birth certificate with seal. Child Must be 5 years of age by August 31st, 2021.
• Two forms of proof of residency in Beverly (Click here for list of acceptable documents)
• Updated Immunization / Proof of Physical Exam Records

If you have any technical issues with this form please email feedback@beverlyschools.org

Registration Type	Resident School Choice Foreign Exchange
Name
Nickname
Gender	Male Female
Date of Birth
Family Military Status	Not enrolled as Member of a Military family Yes, child of active duty member Yes, child of member who died on active duty Yes, child of members or veterans who are medically discharged or retired for 1 year
Student Lives With (Check all that apply)	Both Parents Mother Father Co-parent Stepmother Stepfather Guardian Family/Group Care Foster Care Other

Street Address:
City:
State:
Zip Code:

Please include at least one contact, including parents/guardians.

Please list anyone who is NOT authorized to pick up student.
Documentation will be required.

Not Authorized Name

Not Authorized Relationship

Health Conditions

Check all that apply

ADHD	Allergies	Anemia	Asthma/Reactive Airway
Autism/PDD	Celiac/Stomach Issues	Concussion/Head Injury	Diabetes
Epilepsy/Seizures	Fainting	Hearing Loss	Heart Problems
Hepatitis	Kidney Disease	Liver Disease	Psychiatric
Vision Problem	Other (Please specify)	Other Health Conditions

Allergies

Over the counter medications

I give permission for the nurse to administer the following

Acetaminophen (Tylenol)	Aloe Vera Gel	Anaphylaxis (epinephrine Administration)	Bacitracin ointment
Benadryl	Calamine Lotion	1% Hydrocortisone Ointment	Ibuprofen (Advil or Motrin) (Grade 5-12)
Pramozine HCL 1% (sting relief pads)	Tums (Grade 5-12)

Doctor and Insurance information

Physician	Physician Phone
Medical Insurance	Medical Insurance Policy #
Dentist	Dentist Phone
Dental Insurance	Dental Insurance Policy #

Medications

Remove	Medication	Medication Dose
Remove	Medication	Medication Dose
Remove	Medication	Medication Dose
Remove	Medication	Medication Dose
Remove	Medication	Medication Dose
Remove	Medication	Medication Dose

Vaccination Exemption	N/A Medical Religious
Medical Transport Consent	No Yes

Are you Hispanic or Latino? No: not Hispanic or Latino Yes: Hispanic or Latino: Cuban, Mexican, Chicano, Dominican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race.

What is your race? (Please check all that apply) White: a person having origins in the peoples of Europe, the Middle East or North Africa. Black/African American: a person having origins in the black racial groups of Africa. American Indian or Alaskan Native: a person who identifies a tribal affiliation with peoples of the Americas. Asian: Hawaiian/Pacific Islander: a person having origins in Hawaii, Guam, Samoa, or other Pacific Islands peoples.

Last School Attended School Name City State/Country IEP No Yes (Please provide copy) 504 No Yes (Please provide copy) LEP Services No Yes Migrant Status State Ward No Yes Has student formerly attended Beverly Public Schools? No Yes Name of Beverly School Dates attended Has student ever been expelled? No Yes Has student ever been charged with a felony? No Yes

Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student's home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.

Country of Origin

Date first Enrolled in ANY U.S. school

Has your child completed three (3) academic school years in any state of the United States? No Yes

What is the native language(s) of each parent/guardian? Mother Father Guardian Mother Father Guardian

What language(s) are spoken with your child (Include relatives: grandparents, uncles, aunts, etc... and caregivers) Seldom Sometimes Often Always Seldom Sometimes Often Always

What language did your child first understand and speak?

What language do you use most with your child?

What other languages does your child know? (Check all that apply) Speak Read Write Speak Read Write

What languages does your child use? Seldom Sometimes Often Always Seldom Sometimes Often Always

Will you require written information from school in your native language? No Yes

Will you require an interpreter/translator at Parent-Teacher meetings? No Yes

The Federal McKinney-Vento Education Homeless Education Assistance Act is designed to ensure educational rights and protections for students experiencing homelessness. Homelessness is defined as children and youth who "lack a fixed, regular, and adequate nighttime residence."

Consistent with the Massachusetts Department of Elementary and Secondary Education guidelines, the Beverly Public Schools afford homeless students and unaccompanied youth special consideration in addition to access to the same free, appropriate public education and opportunities thereof, that is provided to all other children and youth living in Beverly. The district will enroll homeless students even if they do not have the documents required for enrollment, such as school records, medical records, or proof of residency. Homeless students and unaccompanied youth are entitled to receive free and reduced school meals, transportation, English language services, vocational and technical services, gifted and talented services, special education, all extra curricular activities and Title 1 services.

Do you have a fixed, regular, and adequate nighttime residence? No Yes

If no, please select the description that best describes your primary nighttime residence Shelter Unaccompanied Youth Hotel/Motel Double-up Unsheltered Emergency/Transitional Placement

A formal early childhood program is participation in a public school preschool, licensed community-based preschool/child care, Head Start program and/or licensed family child care provider for one month or more.

Has your child participated in at least one formal early childhood program (i.e., providers/programs) since September 2020 (when your child was 4)? No Yes Don't Know

If no or don't know, did your child participate in a CFCE or PCHP program? No Yes - Coordinated Family and Community Engagement (CFCE) Yes - Parent-Child Home Program (PCHP) Yes - Both CFCE and Parent-Child Home Program

Stop here if your child did not attend an early childhood program this year (2020-2021)

What type of early childhood program(s) has your child attended since September 2020 (when your child was 4)? Licensed Family child care Licensed Center-based care, including public preschool, Head Start, community-based preschool Both family child care and center-based program Family child care and/or center-based care in a program located outside of the United States

On average during this year (September 2020 through August 2021) how much time per week did/will your child spend in an early childhood program(s)? Less than an average of 20 hours per week An average of 20 or more hours per week

If you select to not submit these forms with your online registration you will be contacted by the registrar to provide the requested documentation

A certified original birth certificate with seal. Child Must be 5 years of age by August 31st, 2021.

Two forms of proof of residency in Beverly (Click here for list of acceptable documents)

Updated Immunization / Proof of Physical Exam Records

Acceptable Use Agreement Click here for Acceptable Use Agreement	No Yes
Age Appropriate Discrimination/Harassment Click here for Age Appropriate Discrimination/Harassment	No Yes
BPS Video/Media Permission Click here for BPS Video/Media Permission	No Yes
Medication Administration Click here for Medication Administration	No Yes
Medicaid Consent Click here for Medicaid Consent	No Yes
Confirmation of Daily Student Symptoms Checking Click here for Confirmation of Daily Student Symptoms Checking	No Yes

2020-2021 District Calendar Pedestrian and bike safety Peanut free building letter Peanut free snack list Dental Clinic Form Directions Dental Clinic Consent Form Immunization Letter Non-custodial Parent Letter Food Service Documents Free and reduced lunch application directions Free and reduced lunch application Free and reduced lunch application online Frequently asked questions POS System BPS Procedures Acceptable Use Procedure

Parent/Guardian name: