TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

PRESCHOOL REGISTRATION FORM FOR 2021-2022

AVAILABLE FEBRUARY 15TH – MARCH 5TH

MANDATORY REGISTRATION / RESIDENCY REQUIREMENTS

Applications are available to download from our websitewww.teaneckschools.org or can be picked up atthe Teaneck Board of Education Central Registration Office located at 651 Teaneck Road. Registration Office hours vary by time of year, please call (201) 833-5512 to confirm hours.

Regular Registration Office hours are as follows: Monday through Friday 9:00 a.m. – 3:30 p.m.
(The office will be closed for lunch from 12:00 p.m. to 1:00 p.m.)

If you have a question regarding residency or registration requirements, please conMtasc.t Rose Antinori, Registrar at (201) 833-5512 or via email at prekregistration@teaneckschools.org.

All applications must be returned with the following:

(All documents must be officially translated in English)

A. Completed Application

B. Original Birth Certificate (Passport can be used to establish official date of birth if birth certificate is not available).

C. Record of Immunization. New Jersey State Law prohibits students from entering school without a Record of Immunization. Documentation must have the student’s legal name.

D. Physical Form

E. Proof of Residency – See next page for list of acceptable proof of residency.

F. Custodial documents

G. Free and Reduced lunch application

PLEASE NOTE: Completion of this form does not guarantee your child will be placed in our Preschool Program.

ONLY COMPLETE APPLICATIONS WITH ALLL REQUIREMENTS SUMITTED WILL BE ACCEPTED

Completed applications can be dropped off at the Teaneck Board of Education Central Registration Office located at 651 Teaneck Road or emailed ONLY to PREKREGISTRATION@TEANECKSCHOOLS.ORG.

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TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

ACCEPTABLE PROOF OF RESIDENCY

OPTION 1: IF YOU OWN A HOME

1. Please provide a copy of your current property tax bill, tax assessment card or a copy of your deed. AND
2.	Most recent utility bill (i.e. PSE&G, water company, cable, telephone bill).

OPTION 2: IF YOU LEASE

1. Please provide a current copy of your lease and it must include the name of the parent/guardian. AND
2.	Most recent utility bill (i.e. PSE&G, water company, cable, telephone bill).

OPTION 3: IF YOU RENT AND DO NOT HAVE A LEASE

1. You must have the owner/landlord of the property complete an Affidavit of Landlord form. The owner of the property must sign the form and have it notarized.

AND

2. The owner must provide a copy of the current property tax bill, tax assessment card or a copy of the deed. AND
3. Copy of your (Parent/Guardian) most recent utility bill (i.e. PSE&G, water company, cable, telephone bill).

OPTION 4: IF IT IS A PRIVATE HOME AND YOU DO NOT PAY RENT

1. You must have the owner/landlord of the property complete an Affidavit of Landlord form. The owner of the property must sign the form and have it notarized. You do not need to disclose any rent amount on the

form. AND
2. The owner must provide a copy of their current property tax bill, tax assessment card or a copy of the deed. AND
3. The parent/guardian must provide a copy of a current utility bill (i.e. PSE&G, water company, cable, telephone bill) or any bill that shows the Teaneck address.

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TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

ETHNICITY AND RACE COLLECTION

In accordance with required Federal StandardsSe[e 1997 Standards, 62 FR 58789 (October 30, 1997)], educational institutions are required to collect racial and ethnic data in the following manner:

ETHNICITY

Hispanic/Latino? (Yes or No)

Hispanic or Latino means a person of Cuban, Mexican, Puerto Rican,South or Central American, or other Spanish culture or origin regardless of race. The term “Spanish origin” can be used in addition to “Hispanic/Latino or Latino.”

RACE

Please select one or more races from the following five racial groups:

(1) American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.

(2) Asian. A person having origins in any of the original peoples of the Far East, South East Asia, or the India subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine islands, Thailand, and Vietnam.

(3) Black or African American. A person having origins in any of the Black racial groups of Africa.

(4) Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

(5) White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

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	TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org
		
PRESCHOOL REGISTRATION FORM FOR SCHOOL YEAR 2021-2022

TOP PORTION TO BE COMPLETED BY TEANECK PUBLIC SCHOOL PERSONNEL SKYWARD ID:	Has the student ever been enrolled in the Teaneck School	504
system?
Yes	No	SA

REGISTRATION DATE:

REGISTRAR:

ENTRY CODE:

GRID CODE (ELEM/MS):

Has the student ever been enrolled in a New Jersey school
system?		HL Yes                           No
CD

SE PK:	Evaluation requested:	G

IEP:	Evaluation requested:	NH

DSR

BOTTOM PORTION OF PACKET TO BE COMPLETED BY PARENT/GUARDIAN STUDENT INFORMATION

Child must be 3 or 4 years old on or before October 1, 2021 to be eligible for the preschool program.

PLEASE NOTE: Completion of this form does not guarantee your child will be placed in our Preschool Program.

MUST BE SUBMITTED NO LATER THAN MARCH 5, 2021

STUDENT FIRST NAME

(As it appears on birth certificate)
	STUDENT LAST NAME
	MIDDLE NAME
	GENDER

M     F
	GRADE FOR 21-22 SCHOOL YEAR
	
STUDENT’S HOME ADDRESS
	CITY
	STATE
	ZIPCODE
	
STUDENT’S MAILING ADDRESS (if different from home address)
	CITY
	STATE
	ZIPCODE
	
NAME OF PARENT(S)/GUARDIAN
	PRIMARY/HOME NUMBER (preferred contact number for school notifications)
	
PERSON ENROLLING STUDENT
	TELEPHONE NUMBER
	RELATIONSHIP TO STUDENT
	
In accordance with required Federal Standards [See 1997 Standards, 62 FR 58789 (October 30, 1997)], educational institutions are required to collect racial and ethnic data in the following manner:

Ethnicity (must check one)	Hispanic	Non-Hispanic

Race (must check one)	White	Black/African Amer	Amer Indian/Alaskan Nat	Asian	Native Hawaiian/Pacific Islander
	
BIRTHDATE
	AGE
	CITY OF BIRTH
	STATE OF BIRTH
	COUNTRY OF BIRTH
	
First Entry Date into a U.S. School: (if student is born outside of the U.S.)
	Language Spoken by Child?
	Native Language Spoken by Child?
	Home Language?
	Did student attend an ESL class in previous school?

Previous School/Daycare Center:

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

FAMILY 1 INFORMATION – PARENT/GUARDIAN LIVING IN THE SAME HOUSEHOLD

Parent/Guardian #1 - Relationship to Student: Mother
			Father
		Legal Guardian
		Foster Parent
				
Emancipated

	
Last Name
	First Name
	Middle Name
	Title
	
Home Address
	
Primary/Home Telephone
	Cell/Alt Phone
	Email Address
	
Employer
	Work Telephone	Ext
	
		Resides With Student
		Allow Web Access

	
		
Parent/Guardian #2 - Relationship to Student: Mother
			Father
		Legal Guardian
		Foster Parent
			
Step-Parent
		DCP&P
			
Last Name
	First Name
	Middle Name
	Title
	
Home Address
	
Primary/Home Telephone
	Cell/Alt Phone
	Email Address
	
Employer
	Work Telephone	Ext
	
		Resides With Student
		Allow Web Access

FAMILY 2 INFORMATION – IF PARENT/GUARDIAN IS LIVING SEPARATELY

Parent/Guardian #1 - Relationship to Student: Mother
		Father
		Legal Guardian
		Foster Parent
	
			DCP&P
	
Last Name
	First Name
	Middle Name
	Title

Mailing Address

Primary/Home Telephone
	Cell/Alt Phone
	Email Address
	
Employer
	Work Telephone	Ext
	
		Extra Mailings
		Contact Not Allowed
		Allow Web Access
		Receive Hard Copy of Report Card

Receive email/phone notification

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TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

Please list any siblings currently attending PK/KG at Teaneck Public Schools

Name of sibling
	Grade
	Age
	Spec Ed
	Attending School

					

Please list any siblings currently applying to the preschool program

Name of Sibling
	Gender
	Age
	Grade applying to

				

				

EMERGENCY CONTACT INFORMATION

First Contact
	
Name	Phone	Relationship
	
Second Contact
	
Name	Phone	Relationship
	
Third Contact
	
Name	Phone	Relationship

I certify that the information provided in this registration is accurate and truthful to the best of my knowledge. I understand that it is my responsibility to inform my child’s preschool program if I move, or if I have any other changes in circumstances that could affect my child’s enrollment or placement. I understand that by participating in the preschool program, my child’s learning and development will be assessed and monitored to support further growth.

Signature of Parent/Guardian _______________________________________	Date _______________

COMPLETION OF THIS FORM DOES NOT GUARANTEE YOUR CHILD HAS BEEN PLACEMENT TO OUR PRESCHOOL PROGRAM. You will be notified byMarch 5, 2021 if your child has been placed in our preschool program. If your child is not placed at this time, their name will be placed on our waitlist.

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

*****IMPORTANT****

PLEASE MAKE SURE TO CHECK BOXES AND INITIAL AFTER ALL THE QUESTIONS ON THIS FORM

SPECIAL SERVICES:

Has your child ever been referred for a special education evaluation? Yes	No	___________

Has your child ever been evaluated by a special education child study team? Yes	No	___________

Has your child ever been classified for special education/related services or for speech services? Yes	No	_______

Do you have any reason to suspect that your child may have a learning, emotional or physical issue? Yes	No	____

Student has an IEP (Individualized Education Program:	Yes	___________	No	___________

Parent/Guardian provided copy of IEP: Yes	No	___________

Referred by Teaneck Case Manager: Yes	No	Teaneck Case Manager Name:_________________________________

Referred to Special Services by Registrar: Yes	No	___________	If no, why?___________________________________

SPECIAL SERVICES:

Student has an ISP (Individualized Service Plan) : Yes	___________ No	___________

Parent/Guardian provided copy of ISP: Yes	No

Referred by Teaneck Case Manager: Yes	No

___________

Teaneck Case Manager Name:_______________________________

Referred to Special Services by Registrar: Yes	No	___________

SPECIAL SERVICES:

Has your child ever had a 504 Accommodation Plan: Yes	No	________

Student has a 504 Accommodation Plan:	Yes	___________	No	___________

Parent/Guardian provided copy of 504 Accommodation Plan: Yes	No	___________

Referred by Teaneck Case Manager: Yes	No	Teaneck Case Manager Name:_________________________________

Referred to Special Services by Registrar: Yes	No	___________

SPECIAL SERVICES

Early Intervention by NJ state: Yes	No

Do you have a meeting with a case manager: Yes	Date of meeting: ________________	No

Referred by Teaneck Case Manager: Yes	No	Teaneck Case Manager Name:______________________________

Referred to Special Services by Registrar: Yes	No

Parent/Guardian signature:________________________________________ Date: ___________

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

CERTIFICATE OF RESIDENCY

I, __________________________________ hereby certify that the statements hereinafter set forth are true: (Name of parent/Legal guardian*)

I am the __________________________ of _____________________________________________________ (Father, Mother, Legal Guardian*)	(Student Name and Age)

______________________________________________________________________________________ who

is an applicant for admission to the Teaneck Public Schools.

This applicant/student resides with me and _________________________________________________________ (List all individuals with whom you reside)

____________________________________________________________________________________________

at ___________________________________________________________________ in the Township of Teaneck. (Residence address)

We have been in actual residence at this address since _______________________________________________ (Month / Day / Year)

Mark the forms of proof you are providing to demonstrate your physical address:
 Copy of Tax Bill or Tax Assessment Card

 Copy of Deed

 Copy of Current Lease Agreement

 Affidavit of Landlord

 Copy of Utility Bill

1. Does Parent/Guardian OWN or RENT home address: _______________________________________________

2. If Mother/Father of applicant/student lives in a separate household:

Reason:	 Divorced	 Separated	 Other:_________________________________________

Address:___________________________________________________________________________________

3. Is there a custodial court order or written agreement designating the district for school attendance?
Circle YES or NO. If yes, please submit a copy of the written agreement to this form at the time of registration.

4. Does the student reside with one parent for the entire year? Circle YES or NO. If so, with which parent at what address:_________________________________________________________________________________________

5. If the student does not reside with one parent for the entire year, explain the portion of time the student resides with each parent and at what addresses. _______________________________________________________________________________________________

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

7. If you are claiming to be an emancipated student, are you living independently in your own permanent home in the district?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

FOR YOUR INFORMATION:

I have been advised that the Board of Education of the Township of Teaneck will not accept non-resident pupils and that the following are the only exceptions permitted to the established policy:

A. Any students whose parents move out of Teaneck during a current school year may complete only the current school year provided that the proportionate tuition rate be paid in advance to the Board Secretary.
B. Students whose parents have pending arrangements for establishing residence within the district may enroll and attend school during any particular month provided that the full tuition rate for that month is paid in advance to the Board Secretary.
C. Should further time be involved in establishing residence, the parents may submit to the principal, affidavits in support of their declared plans or situation. If these are approved, the parents will be permitted to continue the attendance of their children by paying the next full monthly tuition rate in advance to the Board Secretary.

D. Longer periods of attendance beyond two calendar months must be approved by the Board of Education.

The purpose of this certificate of residency is to secure admission of said application into the Public School System of the Township of Teaneck as a resident student.

________________________________________ (Parent/Legal Guardian* Signature)

_________________________________________ TBOE Attendance Officer Initials

Registration Conditional

*Guardianship papers must be produced for examination.	Parent/Guardian: ___________________

	DISTRICT OFFICE USE ONLY

Physical verification of residency by TBOE Attendance Officer:_____________________________________

Date of verification:_____________________________________________________________________

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

STUDENT NAME: ___________________________________ DOB:_____________ AGE:____     GRADE:_____	IEP: YES	NO

PARENT/LEGAL GUARDIAN: ___________________________________________________ PHONE: ________________________

LAST PERMANENT PLACE OF RESIDENCY IN NJ:

ADDRESS:________________________________________________________________________

CITY, STATE, ZIP CODE:____________________________________________________________

Number of years/months at last permanent address: ____________________________________

Move in date: _______________________	Move out date: _________________________

LAST SCHOOL ATTENDED: __________________________________________________________ GRADE AT LAST SCHOOL:________

LAST PERMANENT PLACE OF RESIDENCY OUT OF STATE:

ADDRESS:________________________________________________________________________

CITY, STATE, ZIP CODE:_____________________________________________________________

Number of years/months at last permanent address: ____________________________________

Move in date: ___________________________ Move out date: _____________________________

LAST SCHOOL ATTENDED: ___________________________________________________________ GRADE AT LAST SCHOOL:________

STUDENT IS PRESENTLY:	IN A SHELTER	IN A MOTEL/HOTEL	DOUBLED UP WITH FAMILY/FRIENDS	KNOWN TO DCP&P

OTHER _______________________________________

CURRENT PHYSICAL LOCATION OF STUDENT RESIDENCE: ______________________________________________ AS OF ______________

RESIDENCE STATEMENT: _______________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Under penalty of perjury under the laws of this state, I declare that the information provided here is true and correct and of my own personal knowledge

and that, if called upon to testify, I would be competent to do so. I also understand that I must notify the Teaneck Public School District of any changes as

soon as they occur. I give my approval for this document to be shared with the District McKinney-Vento Liaison.

Parent/Guardian signature: ________________________________Date_______________

Parent/Guardian print name: _________________________________________________

OSS: ___________________________Date_________

FOR OFFICE USE ONLY ELIGIBLE UNDER MC KINNEY-VENTO ( ) YES     (     ) NO

RESIDENCY:___________________________________________________________________________________________________

DISTRICT OF RESPONSIBILITY:___________________________________________________________________________________

NOTIFICATION SENT TO:	SCHOOL PRINCIPAL	BUSINESS ADMINISTRATOR	DIRECTOR OF SPECIAL SERVICES	McK-V COUNTY LIAISON

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

Home Language Survey Parent/Guardian Questionnaire

PLEASE PRINT

This home language survey is to be completed at the time of registration by all who are registering within the Teaneck School District. The information provided is used to determine if another language is spoken in the home. The questions should be completed by the primary caregiver (with translators available, if and when needed).

Child’s name: ____________________________________________	Date: __________ (first)	(middle)	(last)

Child's Date of Birth : ____________________________________________

Person completing the survey: [ ]Mother [ ]Father [ ]Grandparent [ ]Guardian [ ]Other

Please tell us about your child:

1.	What language did the child learn when he/she first began to talk? __________________________

2.	What language does the family speak at home most of the time? ____________________________

3.	What language(s) does the primary caregiver (s) speak to the child most of the time? ____________

4.	What language(s) does the child speak to his/her primary caregiver (s) most of the time? _________

5.	What language(s) does the child speak to his/her brothers and sisters most of the time? __________

6.	What language does the child speak to his/her friends most of the time? _______________________

7.	In which language do you wish to receive information from the school? _______________________

8.	What name do you use for your child (if different from above)? _____________________________

Sources:
Questions 1 – 8 are based on the NJ DOE Home Language Survey that was adapted from the sample survey in A Manual for Community Representatives of the Title VI Steering Committee, published 9/76 by the Institute for Cultural Pluralism, Lau General Assistance Center, San Diego University, San Diego, CA 92182

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

Skyward Family Access is a web-based application that allows you to track information regarding your child’s progress for the current year. You may access this program by connecting to our secured server to view assignments, attendance, report card grades, and other school information.

Skyward Family Access Parental Use and Responsibility Acknowledgement

I, _______________________________________________________________________________________, (parent/guardian name)
Parent/Guardian of

_________________________________________________________________________________________ (student name)

_________________________________________________________________________________________ (school student will be attending)

acknowledge that I have requested and received authorization to use Skyward Family Access. I understand that I share in the responsibility of keeping safe the data of my child(ren). My responsibilities include reporting any security concerns to the school district, guarding my password, changing my password on a regular basis, and promptly logging off of my Skyward Family Access session when finished or before leaving my computer. I understand that the school district may without prior notification disable my accounts as part of the overall security procedures.

_________________________________ Print Parent/Guardian Name

____________________________________ Signature of Parent/Guardian Name

Date: ____________________________

NAME OF PARENT/LEGAL GUARDIAN WHO ARE ALLOWED FAMILY ACCESS
	Parent/Guardian initial receipt of login and password

		

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TEANECK PUBLIC SCHOOLS One Merrison Street Teaneck, New Jersey 07666 www.teaneckschools.org

AFFIDAVIT OF LANDLORD

STATE OF NEW JERSEY) SS:
COUNTY OF BERGEN	)

I _____________________________________ of full age, and being duly sworn upon his or her oath, according to law, deposes and says:
1. I am the owner of property located at _____________________________________________, in the Township of Teaneck.
2. ____________________________________ is a tenant and has been a tenant at the above premises since ______________(month/day/year). A copy of this tenant’s lease, if same is in written form, is attached hereto. In the event that tenant does not have a written lease, the pertinent terms of said lease are as follows:
A. Circle one of the following: Month to Month / Year to Year B. Rental amount $ _______________ per ______________ C. The names of permissible tenants are as follows:

1. ____________________________ 2. ____________________________
3. ____________________________

4. _______________________________ 5. _______________________________
6. _______________________________

3. I am making this affidavit knowing that the Board of Education of the Township of Teaneck will rely on same in determining whether ________________________________ will be considered a pupil who is entitled to an education free of charge.

I understand that if any of the statements made by me are willfully false that I am subject to punishment.

____________________________________ (LANDLORD)
Sworn and subscribed before

me this _______ day of ________

__________________________ (A Notary Public)

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TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

Physical Examination

Student’s name: Parent/Guardian name: Phone #:
Health Care Provider: Address:

Age: Address: School: Phone:
City/State/Zip:

DOB:	Sex:

Grade: Fax:

PHYSCICAN / HEALTH CARE PROVIDER – PLEASE COMPLETE FORM

Exam Date:	Height:	Weight:	BP:	Pulse:

Vision: R 20/	L 20/	Corrected:	Y	N	Glasses:	Y	N	Hearing:	R	L

	Normal
	Abnormal Findings
	Comments
	
General Appearance
				
Head/Neck
				
Eye/Sclera/Pupils
				
Ears:
				
Gross Hearing
				
Nose/Mouth/Throat
				
Lymph Glands
				
Heart: Murmurs/Rhythms
				
Lungs: Auscultation/Percussion
				
Chest Contour
				
Skin
				
Abdomen:
Assessment (inc. liver/spleen)
				
Tanner Stage:
Testes/Onset of Menses
				
Hernia
				
Neck/Back/Spine: Range of motion
				
Scoliosis
				
Upper Extremities
				
Lower Extremities
				
Neurological:
Balance & Coordination Romberg
				
Evidence of Marfan Syndrome

Most recent Immunizations / Dates:

Medications currently in use:

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TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

Additional Observations / Comments:

HISTORY: Please indicate all areas where disease or alterations have occurred and explain below:

Allergies/Anaphylaxis Asthma / Respiratory Cardiovascular / Murmur Childhood diseases

Eczema / Skin Endocrine Gastrointestinal Genitourinary

Hospitalizations / Surgery Musculoskeletal Neurological / Seizures Other

Explanation/Comments:

ACTIVITY CLEARANCE:
A.	Student may participate in physical education and all sports:	YES	NO

B.	Cleared after completing evaluation for:

C.	NOT CLEARED FOR: (check all that apply)

Collision Strenuous

Contact Moderate

Non-Contact Non-Strenuous

Diagnosis:

Recommendations:

VACCINATIONS:
	Date
	Date
	Date
	Date
	Date
	
DPT / DTaP
						
Tdap
						
OPV / IPV
						
MMR
						
Measles
						
Mumps
						
Rubella
						
Hepatitis A
						
Hepatitis B
						
HIB / Prohibit
						
Varicella
						
Pneumococcal (PCV7)
						
Meningococcal
						
Influenza
						
Other:
						
Other:

LEAD SCREENING:	Date test performed:	Result:

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TEANECK PUBLIC SCHOOLS 651 Teaneck Road Teaneck, New Jersey 07666 www.teaneckschools.org

TUBERCULOSIS TESTING:
Mantoux:	Date planted:	Date read:	Result:

Chest X-ray INH Therapy:

Date planted: Date:
Date started:

Date read: Result: Dosage:

Result:

Duration of Tx:

Physician / HCP Signature	Date	Stamp

Page | 16	Revised: 2/2/2021

TEANECK BOARD OF EDUCATION Business Office One Merrison Street Teaneck, NJ 07666
Phone: 201-833-5527	Fax: 201-833-2274

August 2020

Dear Parent/Guardian:

Children need healthy meals to learn. The Teaneck Public Schools offers healthy meals every school day at the prices listed below. Your children may qualify for free meals or for reduced price meals.

FULL PRICE
	
REDUCED PRICE

Elementary
	
Middle
	
High
	
Elementary
	
Middle
	
High

National School Lunch
	$2.90
	$3.05
	$3.40
	
$0.00
	
$0.00
	
$0.00
	
School Breakfast

$1.50

$1.75

$1.75

$0.00

$0.00

$0.00
	
After School Snack

N/A
	
N/A

N/A

N/A

N/A

N/A
	
Special Milk Program

N/A

N/A

N/A

Not Applicable

Not Applicable

Not Applicable
	
Split Session Milk Program

N/A

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable
	
N/A - Not Applicable
	
	This packet includes an application for free or reduced price meal benefits, and a set of detailed instructions.
		
	For a convenient way to fill out the meal application, go to
		
	https://www.teaneckschools.org/OnlineLunchApplication.aspx or you can go directly to application on
		
	MySchoolApps website at www.myschoolapps.com.

1.	WHO CAN GET FREE OR REDUCED PRICE MEALS?

· All children in households receiving benefits from NJ SNAP or NJ TANF/WorkFirst-NJ are eligible for free meals.
· Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals.
· Children participating in their school’s Head Start program are eligible for free meals.

· Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.

· Children may receive free or reduced price meals if your household’s income is within the limits on the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart.

FEDERAL INCOME CHART
For school Year 2020-2021
		
Household Size
	
Yearly
	
Monthly
	
Weekly
		
1
	23,606
	
1,968
	454

2
	
31,894
	
2,658
	
614

3
	
40,182
	
3,349
	
773

4
	
48,470
	
4,040
	
933

5
	
56,758
	
4,730
	
1,092

6
	
65,046
	
5,421
	
1,251

7
	
73,334
	
6,112
	
1,411
		
8
	
81,622
	6,802
	1,570

For each additional person, add:
	
+8,288
	
+691
	
+160

2.	HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and haven’t been told your children will get free meals, please call or e-mail your school, homeless liaison or migrant coordinator.
3.	DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to one of your children’s schools.
4.	SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you got carefully and follow the instructions. If any children in your household were missing from your eligibility notification, contact your school immediately.
5.	CAN I APPLY ONLINE? If available, you are encouraged to complete an online application instead of a paper application. The online application has the same requirements and will ask you for the same information as the paper application. Contact your school if you have any questions about the online application.
6.	MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year.
7.	I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please send in an application.
8.	WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report.
9.	IF I DON'T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.
10. WHAT IF I DISAGREE WITH THE SCHOOL'S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to:

Hearing Officer Name: MELISSA SIMMONS Address: TEANECK PUBLIC SCHOOLS, 1 MERRISON STREET, TEANECK, NJ - 07666
11. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. citizens to apply for free or reduced price meals.
12. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
13. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.
14. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or receive Family Subsistence Supplemental Allowance payments, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income.
15. WHAT IF THERE ISN'T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a separate piece of paper, and attach it to your application.
16. MY FAMILY NEEDS HELP. ARE THERE ANY PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for NJ SNAP or other assistance benefits, contact your local assistance office, call 1-800-687-9512 or go to https://oneapp.dhs.state.nj.us/default.aspx. You can also contact NJ FamilyCare or Medicaid at
1-800-701-0710 or www.njfamilycare.org for information regarding health insurance for your family. For the WIC Program, call 1-800-328-3838 or go to www.nj.gov/health/fhs/wic.

If you have other questions or need help, call (201)833-5511

Sincerely,

Melissa Simmons

MELISSA SIMMONS
School Business Administrator Board Secretary

Check all that apply

EarningsfromWork
	Weekly
	Bi-Weekly
	2xMonth
	Monthly

					

					

Child Support/Alimony
	Weekly Bi-Weekly
	2xMonth
	Monthly

					

					

Application #:
2020-2021 Application for Free and Reduced Price School Meals Complete one application per household. Please type or use a pen (not a pencil).

Available online at:

Definition of Household	Child’s First Name	MI	Child’s Last Name	[press spacebar to advance]	School Name (Abbr.) Grade Member: “Anyone who is
living with you and shares income and expenses, even if not related.”

Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.

Student attends this school district?
Yes     No

Migrant Worker, Foster     Homeless, Child       Runaway

STEP 2
	Do anyHousehold Members (including you) currentlyparticipate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?	YES	NO

If you answered NO > Complete STEP 3.	If you answered YES > Write a case number here then go to STEP 4 (Do not complete STEP 3)	Case Number:

Write only one case number in this space.

	ReportIncomeforALLHouseholdMembers (Skipthisstepifyouanswered‘Yes’toSTEP2)

Child income
		Weekly
	Bi-Weekly
	2xMonth
	Monthly

How often? A. Child Income

Sometimes children in the household earn or receive income. Please include the TOTAL income received by all
Household Members listed in STEP 1 here.	$

B. All Adult Household Members (including yourself)

Are you unsure what income to include here?

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any ﬁelds blank, you are certifying (promising) that there is no income to report.

Flip the page and review the charts titled “Sources of Income” for more information.

The “Sources of Income for Children” chart will help you with the Child Income section.

The “Sources of Income for Adults” chart will help you with the All Adult Household Members section.

Name of Adult Household Members (First and Last)

$

$

$

$

$

How often?	Public Assistance/	How often?

$

$

$

$

$

Pensions/Retirement/ All Other Income

$

$

$

$

$

How often?

Weekly     Bi-Weekly 2xMonth     Monthly

Total Household Members (Children and Adults)

LastFourDigitsofSocialSecurityNumber(SSN)of

PrimaryWageEarnerorOtherAdultHouseholdMember

X
	X
	X

Check if no SSN

STEP 4
	Contact information and adult signature.
	Mail Completed Form To:

X
	X

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal beneﬁts, and I may be prosecuted under applicable State and Federal laws.”

Street Address (if available)	Apt #	City	State	Zip	Daytime Phone and Email (optional)

Printed name of adult signing the form	Signature of adult	Today’s date

PublicAssistance/
AllOtherIncome

INSTRUCTIONS
	Sources of Income

Do not ﬁll out
	For School Use Only

Sources of Income for Children
	
SourcesofChildIncome
	Example(s)
	
- Earnings from work
	- A child has a regular full or part-time job where they earn a salary or wages
	
- Social Security
- Disability Payments - Survivor’s Beneﬁts
	-A childis blindordisabledandreceivesSocial Securitybeneﬁts
-A Parentis disabled,retired,ordeceased,and theirchildreceivesSocialSecuritybeneﬁts
	
-Income from person outside the household
	- A friend or extended family member regularly gives a child spending money
	
-Income from any other source
	- A child receives regular income from a private pension fund, annuity, or trust

Sources of Income for Adults
	
EarningsfromWork
	
Alimony/ChildSupport
	Pensions/Retirement/
	
- Salary, wages, cash bonuses
- Net income from self-employment (farm or business)

If you are in the U.S. Military:

- Basicpayandcashbonuses (doNOTincludecombatpay, FSSAorprivatizedhousing allowances)
- Allowancesforoff-base housing,foodandclothing
	- Unemployment beneﬁts - Worker’s compensation - Supplemental Security Income (SSI)
- Cash assistance from State or local government
- Alimony payments
- Child support payments - Veteran’s beneﬁts
- Strike beneﬁts
	- Social Security (including railroad retirement and black lung beneﬁts)
- Private pensions or disability benefits
- Regular income from trusts or estates
- Annuities
- Investment income - Earned interest
- Rental income
- Regular cash payments from outside household

OPTIONAL
	Children's Racial and Ethnic Identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

Ethnicity(checkone):	Hispanic or Latino	Not Hispanic or Latino

Race(checkoneormore): American Indian or Alaskan Native	Asian	Black or African American	Native Hawaiian or Other Paciﬁc Islander	White

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include thelast fourdigitsof thesocial securitynumber of the adulthouseholdmember who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identiﬁer for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine beneﬁts for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

Inaccordance with Federal civil rightslaw andU.S.Department of Agriculture (USDA)civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race,color,national origin,sex, disability,age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for beneﬁts. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made availablein languages other than English.

To ﬁle a program complaintof discrimination, complete the USDA Program DiscriminationComplaint Form, (AD-3027)foundonlineat:http://www.ascr.usda.gov/complaint_ﬁling_cust.html,andatanyUSDA office,or writea letter addressed to USDA andprovide in theletter all of the information requested in the form.To request a copy of thecomplaintform, call (866) 632-9992. Submit your completed form or letter to USDA by:

mail civil rightscomplaintsonly to: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW Washington, D.C. 20250-9410

fax:	(202) 690-7442; or

email:	program.intake@usda.gov.

This institution is an equal opportunity provider.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12 How often?

Total Income	Weekly     Bi-Weekly     2xMonth     Monthly  Annual 	Household Size

Categorical Eligibility

Eligibility:

Free
	Reduced
	Denied

Determining Official’s Signature	Date	Conﬁrming Official’s Signature	Date	Verifying Official’s Signature	Date