TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

PRESCHOOL REGISTRATION FORM FOR 2023-2024

AVAILABLE FEBRUARY 13th - MARCH 31st

MANDATORY REGISTRATION / RESIDENCY REQUIREMENTS

Applications are available to download from our website at www.teaneckschools.org/Residency & Registration/Grades Preschool (PK3, PK4) or be picked up at the following two locations:

1. Teaneck Early Learning Center located at 479 Maitland Avenue. Office hours are Monday through Friday from 9:00 a.m. – 3:30 p.m.

2. Teaneck Board of Education Central Registration Office located at 651 Teaneck Road. Office hours are Monday through Friday from 9:00 a.m. – 3:30 p.m.

If you have any questions regarding residency, registration requirements, or application, please contact Ms. Yamile Fernandez at (201) 347-3486 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. The 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.

Page | 1	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

ONLY COMPLETE APPLICATIONS WITH ALL REQUIREMENTS SUMITTED WILL BE ACCEPTED

Completed applications should be dropped off by appointment only at the Teaneck Early Learning Center located at 479 Maitland Avenue or emailed ONLY to PREKREGISTRATION@TEANECKSCHOOLS.ORG. To make an appointment, please contact Ms. Yamile Fernandez at (201) 347-3486.

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.

Page | 2	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

ETHNICITY AND RACE COLLECTION

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

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. Theterm “Spanish origin” canbe 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 Indian 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.

Page | 3	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

SKYWARD ID:
	Has the student ever
	been enrolled in the Teaneck School No
	Supt Approval

HL

Disp Storm

Non Eng

504
	
	system? Yes

				
REGISTRATION DATE:
	Has the student ever been enrolled in a New Jersey school system?	Yes	No
		
REGISTRAR:
	SE PK:
	Evaluation requested:
		
ENTRY CODE:
	IEP:
	Evaluation requested:
		
GRID CODE (ELEM/MS):
				
	BOTTOM PORTION OF PACKET TO BE COMPLETED BY PARENT/GUARDIAN STUDENT INFORMATION

PRESCHOOL REGISTRATION FORM FOR SCHOOL YEAR 2023-2024 TOP PORTION TO BE COMPLETED BY TEANECK PUBLIC SCHOOL PERSONNEL

Child must be 3 or 4 years old on or before October 1, 2023 to be eligible for the preschool program.

PLEASE NOTE: COMPLETION OF THIS FORM DOES NOT GUARANTEE YOUR CHILD PLACEMENT IN OUR PRESCHOOL PROGRAM.

MUST BE SUBMITTED NO LATER THAN MARCH 31, 2023

STUDENT FIRST NAME (As on birth certificate)
	STUDENT LAST NAME
	MIDDLE NAME
	GENDER

M	F
	GRADE SCHOOL YEAR 23-24
	
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:

Page | 4	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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 ☐
	
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

Page | 5	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

Please list any siblings currently attending PK 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 X_________________________________	Date _______________

COMPLETION OF THIS FORM DOES NOT GUARANTEE YOUR CHILD PLACEMENT IN OUR PRESCHOOL PROGRAM.

Page | 6	Revised: 12/8/2022

	TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org
		
	**PLEASE MAKE SURE TO-- ANSWER
	& INITIAL ALL QUESTIONS – ON THE LINE AFTER**

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: X________________________________________ Date: ___________

Page | 7	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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: Refer to Options 1-4 from page 2 ◻ Copy of Tax Bill or Tax Assessment Card and utility bill
◻ Copy of Deed and utility bill
◻ Copy of Current Lease Agreement and utility bill ◻ Affidavit of Landlord – see option 3 or 4
◻ Other (pending approval)

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. _______________________________________________________________________________________________

Page | 8	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

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.

X________________________________________ (Parent/Legal Guardian* Signature)

_________________________________________ TBOE Attendance Officer Initials

Registration Conditional ☐

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

	DISTRICT OFFICE USE ONLY

Physical verification of residency by TBOE Attendance Officer: _____________________________________

Date of verification: _____________________________________________________________________

Page | 9	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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: X ________________________________Date X_______________

Parent/Guardian print name: X_________________________________________________

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

Page | 10	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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

Page | 11	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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.

X_________________________________ Print Parent/Guardian Name

X____________________________________ Signature of Parent/Guardian Name

Date: ____________________________

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

		

Page | 12	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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)

Page | 13	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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:

Page | 14	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
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:        YE                     N S                        O

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

Page | 15	Revised: 12/8/2022

TEANECK PUBLIC SCHOOLS PK REGISTRATION 479 Maitland Avenue
Teaneck, New Jersey 07666 www.teaneckschools.org

TUBERCULOSIS TESTING: Mantoux:	Date planted:

Date planted:

Date read:

Date read:

Result:

Result:

Chest X-ray

INH Therapy:

Date:

Date started:

Result

Dosage:	Duration of Tx:

Physician / HCP Signature	Date	Stamp

Page | 16	Revised: 12/8/2022

Check all that apply

EarningsfromWork
	Weekly
	Bi-Weekly
	2xMonth
	Monthly

					

					

Child Support/Alimony
	Weekly Bi-Weekly
	2xMonth
	Monthly

					

					

Application #:
2022-2023 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