For Office Use Only

  • Student ID Number: ▁▁▁▁▁▁  MAPS: ▁▁▁▁▁▁  Referred to: Bilingual/ESL □  Special Services □

    □ New   □ Returning School  Grade: ▁▁▁▁▁▁  Coming from:▁▁▁▁▁▁

    Enrollment Date: ▁▁▁▁▁▁   Start Date: ▁▁▁▁▁▁

    Bus number: ▁▁▁▁▁▁   Time: ▁▁▁▁▁▁    Location of pick up (a.m.): ▁▁▁▁▁▁

    Bus number: ▁▁▁▁▁▁   Time: ▁▁▁▁▁▁   Location of pick up (p.m.): ▁▁▁▁▁▁

    □ Proof of Age □ Immunization Records □ Proof of Residence □Proof of Custody/Guardianship □ DS2999



Registration Form

  • Student’s Last Name:▁▁▁▁▁▁     First:▁▁▁▁▁▁     Middle:▁▁▁▁▁▁

    Date of Birth:▁▁▁▁▁▁   □ Male   □ Female

    Residence Address:▁▁▁▁▁▁   City/State/Zip:▁▁▁▁▁▁

    Mailing Address:▁▁▁▁▁▁  City/State/Zip:▁▁▁▁▁▁



State Required Information

  • □ Yes, Hispanic  □ No, Non-Hispanic              Primary Language spoken at Home:▁▁▁▁▁▁

    Race (Please choose one):

    □ American Indian or Alaskan Native     

    □ Asian      

    □ Native Hawaiian or Other Pacific Islander

    □ Black or African American                   

    □ White

    Is the parent on active duty in the Armed Forces □ Yes  □ No 

    Dates Active: From▁▁▁▁▁▁:   To:▁▁▁▁▁▁ 

     



Parent Guardian Information

  • Mother/Guardian/Foster Parent Full Name:▁▁▁▁▁▁     D.O.B.:▁▁▁▁▁▁

    Address (if different from Student):▁▁▁▁▁▁

    Home Phone:▁▁▁▁▁▁  Work Phone:▁▁▁▁▁▁  Cell Phone:▁▁▁▁▁▁ 

    Email (please print clearly):▁▁▁▁▁▁ 


    Father/Guardian/Foster Parent Full Name:▁▁▁▁▁▁   D.O.B.:▁▁▁▁▁▁

    Address (if different from Student):▁▁▁▁▁▁

    Home Phone:▁▁▁▁▁▁  Work Phone:▁▁▁▁▁▁  Cell Phone:▁▁▁▁▁▁ 

    Email (please print clearly):▁▁▁▁▁▁ 



List other Children in the District

  • List other Children in the District (form to be completed)


    Name:▁▁▁▁▁▁

    Gender:▁▁▁▁▁▁

    D.O.B:▁▁▁▁▁▁

    Grade:▁▁▁▁▁▁

    Present School:▁▁▁▁▁▁


    Name:▁▁▁▁▁▁

    Gender:▁▁▁▁▁▁

    D.O.B:▁▁▁▁▁▁

    Grade:▁▁▁▁▁▁

    Present School:▁▁▁▁▁▁


    Name:▁▁▁▁▁▁

    Gender:▁▁▁▁▁▁

    D.O.B:▁▁▁▁▁▁

    Grade:▁▁▁▁▁▁

    Present School:▁▁▁▁▁▁


    Name:▁▁▁▁▁▁

    Gender:▁▁▁▁▁▁

    D.O.B:▁▁▁▁▁▁

    Grade:▁▁▁▁▁▁

    Present School:▁▁▁▁▁▁



Parent/Legal Guardian Signature

  • Parent/Legal Guardian Signature:▁▁▁▁▁▁

    Date:▁▁▁▁▁▁



  • Central Registration Office 53 Bedford Ave Middletown, NY 10940

    Telephone (845) 326-1300 Fax (845) 326-1321

    Email: www.middletowncityschools.org

    493940.1 6/2018