Student Registration Form

Required

Student Information

Namerequired
First Name
Middle
Last Name
(mm/dd/yyyy)
Child is:required
U.S. Citizenrequired
Does this child have Health Insurance?required
Is your child's parent or guardian a member of the Armed Forces on active duty or serves on full-time National Guard duty?required
Does your child have any medical conditions such as severe reactions to insect bites, medications, or food which require emergency treatment?required
Student lives with:required

 

Parent/Guardian Information:

 


 


 

If your child becomes ill during the day and needs to leave, please list in order of importance, the names of four adults, including yourself and/or spouse, along with the day time phone numbers. It is understood that those listed have your permission to pick up your child.

 


 


 


 

Has your child been a student in the Ansonia Public Schools before?required

 

List the names of all children in the household, including their date of birth, relationship, and current school.

 


 


 


 

Has your child been educated in the United States for 3 years or more?required
Has your child received/attended any special services/programs? Please select all that apply:
Does your child have an IEP?required
Does your child have a 504 plan?required

 

Is this child Hispanic/Latino?required
What is the child's race? (check one or more, even if you answered yes to the Hispanic/Latino question)required