Student Registration Form

Required

Student Information

Namerequired
First Name
Middle
Last Name
(mm/dd/yyyy) (Must contain a date in M/D/YYYY format)
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.
Must contain a date in M/D/YYYY format

 

Must contain a date in M/D/YYYY format

 

Must contain a date in M/D/YYYY format

 

Must contain a date in M/D/YYYY format

 

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