Student Registration Form

1

Student's Full Name * This field is required.

First Name

Middle Name

Last Name

2

Student's Date of Birth* This field is required.

Date

3

Student's Current Age (Yrs./Mo)* This field is required.

4

Was the student born in the United States?

YESNO

5

Student's NickName (optional)

6

Student Gender* This field is required.

Male

Female

Non-binary

7

Student's Place of Birth (Country/State)* This field is required.

8

If not born in the United States, date entered the U.S.

Date

9

Is the student Hispanic, Latino, or of Spanish origin?

YESNO

10

Select the student's race from the following 5 racial groups* This field is required.

American Indian or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Black

White

11

Brothers/Sisters, Stepbrothers/Stepsisters, or others under 21 living in the household.

12

Primary Phone Number* This field is required.

Area Code

Phone Number

13

Is this a cell phone?* This field is required.

YESNO

14

Primary Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

15

How long have you lived at this address?* This field is required.

16

Housing* This field is required.

Own

Rent

Non-Resident

Shelter

Other arrangement due to lack of house, ex. abandoned apartment building, campground, or car/train/bus shelter (please explain)

17

Please provide a brief explanation in the text box below.

18

If either parent is deceased, please provide the following information.

Relationship

Year of Death

Parent #1

Parent #2

Parent #1

Parent #2

Relationship

Year of Death

Relationship

Year of Death

19

The student currently resides with...* This field is required.

Both Parents / Guardians

Parent / Guardian #1

Parent/ / Guardian #2

20

Are parents legally separated, or presently involved in legal separation/divorce proceedings?* This field is required.

YESNO

21

If yes, please describe the legal status, plus rights of “non-custodial” parent (i.e., visitation, access to child at school, school conferences, etc.). Kindly submit a copy of “Court Order” papers to the main office.

22

If yes, should mailings be sent to both parents/Guardians?

YESNO

23

Do court orders apply (if yes, kindly submit a copy of "Court Order" papers to the main office)

YESNO

24

Primary Household Language* This field is required.

25

Is translation required?

YESNO

26

Parent / Guardian #1: Name* This field is required.

First Name

Last Name

27

Parent / Guardian #1: Relationship to Student* This field is required.

28

Parent / Guardian #1: Email Address* This field is required.

example@example.com

29

Parent / Guardian #1: Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

30

Parent / Guardian #1: Place of Birth* This field is required.

31

Parent / Guardian #1: Date of Birth* This field is required.

Date

32

Parent / Guardian #1: Current Occupation* This field is required.

33

Parent / Guardian #2: Name

First Name

Last Name

34

Parent / Guardian #2: Relationship to Student

35

Parent / Guardian #2: Email Address

example@example.com

36

Parent / Guardian #2: Mailing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

37

Parent / Guardian #2: Place of birth

38

Parent / Guardian #2: Date of Birth

Date

39

Parent / Guardian #2: Current Occupation

40

Doctor's Name* This field is required.

41

Doctor's Phone Number* This field is required.

Area Code

Phone Number

42

Hospital of Choice* This field is required.

43

Hospital Phone Number* This field is required.

Area Code

Phone Number

44

I give my consent for the Pleasantville School District's nurse to administer EpiPen and/or Benadryl Elixir to my child in the event of an allergic reaction.* This field is required.

YESNO

45

Emergency Contact #1: Name* This field is required.

First Name

Last Name

46

Emergency Contact #1: Relationship* This field is required.

47

Emergency Contact #1: Phone Number* This field is required.

Area Code

Phone Number

48

Emergency Contact #2: Name

First Name

Last Name

49

Emergency Contact #2: Relationship

50

Emergency Contact #2: Phone Number

Area Code

Phone Number

51

I give permission for the emergency contacts listed to be able to pick up my child should they require assistance. * This field is required.

YESNO

52

Previous Educational ExperiencePlease share the details of all previous schools the child has attended, including preschools.

53

Was child ever a candidate for retention?* This field is required.

YESNO

54

Was child ever held back a grade?* This field is required.

YESNO

55

Grade(s) held back:

56

General reasons for retention:

57

Was child ever referred for special education/ preschool special ed (CPSE)?* This field is required.

YESNO

58

Was child ever in a special education/preschool special education program (CPSE)?* This field is required.

YESNO

59

Please note any special services child has received to date:* This field is required.

None

Remedial Math

Remedial Reading

English as a Second Language

Counseling (with School Psychologist)

Speech Therapy

Other Tutorial Support

Programs for Gifted/Talented Children

Other

60

Please elaborate on special programs your child has been involved in.

61

What grade will the student be entering in Pleasantville?* This field is required.

62

What is the student's projected start date in the Pleasantville Schools?* This field is required.

63

Is this the first time your child is being registered in the Pleasantville Union Free School District?* This field is required.

YESNO

64

In what year was the student previously registered in Pleasantville?* This field is required.

65

I attest that the information I am providing is complete and accurate.* This field is required.

66

Proof of Residency Requirement

In order to register your child/children in the Pleasantville School District, you need to provide the following proof of residency information to the district:

A deed to the house, a recent mortgage statement, or a Closing Statement from a bank or other lender, or from your attorney; or
An up-to-date lease signed and dated by both tenant and landlord OR notarized Owner and Tenant Affidavits, one completed by the property owner (homeowner/landlord) and one completed by the tenant; or
Notarized Third-Party Affidavit from the homeowner/landlord confirming your residency.

You must also provide...

Two current billing statements from two different service providers. The billing statement must be in the name of the parent/guardian and must state your Pleasantville address as the location of service. For those submitting a Third-Party Affidavit, we can accept bills in the name of either the homeowner/landlord or the parent/guardian; all the other criteria must still be met. Acceptable bills include the following:

Auto Insurance
Cable
Electric
Gas
Homeowner’s or Renter’s Insurance
Moving
Telephone (not cell phone)
Water

After submitting this registration form, you will recieve a follow up email with details on next steps, including additional required documentation. If you have any questions, please feel free to call the District Clerk at 914-741-1400 x10511.