New Student School Registration

Phone (609) 267-1406 X 2004

jgrimm@lumberton.k12.nj.us

2. Date Registered __ _____ 3. Date Entered: __ ____ 4. Entering Grade__ ____

5. Last Name______________________ 6. First Name________________________ 7. Middle Name__________________

8. Birth Date ___ ___ / ___ ___ / ___ ___ ___ ___

9. Race: CHECK ALL THAT APPLY: White____ Black ____ Asian _____ American Indian/Alaskan Native____

Pacific Islander/Native Hawaiian _____

10. Ethnicity: YOU MUST CHECK ONE: Hispanic or Latino____ NOT Hispanic or Latino____

11. Male_____ Female_____

12. Birthplace (U.S. City/State OR Non-U.S. Country) _______________________ 13. Language Spoken at Home_______________

If Non-US Country: US Entry Date_______________________ 1st Entry in US School_______________________

14. Transferred from: Name of School ________________________________________

Address _______________________________________________

City __________________ State______ Zip ________ Phone Number (_ )_________________

15. Home Address

Neighborhood/Development: ____________________________________________

16. Home Telephone # (____) __ _______

Guardian 1 Cell # (_____)______ _____ Guardian 1 e-mail address ____ ___________

Guardian 2 Cell # (_____)_______ ______ Guardian 2 e-mail address _______ ___________

17. Student resides with: Guardian 1 ___ Guardian 2_____ Both Guardians Other (specify)

18. Guardian 1 Name ____________________________________ Work Phone #______________________

19. Guardian 1 Employer _______________________________

20. Guardian 2 Name _____________________________________ Work Phone # _____________________

21. Guardian 2 Employer _________________________________

22. Last Name of Sibling First Name of Sibling Male/Female Date of Birth

23. Emergency Contact Numbers (OTHER THAN GUARDIANS)

a. Name: __________________________ Relationship: __________________ Home Ph. # ( )________________

Address: __________________________ City: State: Zip:

Work Ph. # (____) ______________ Cell Ph. # (____) ________________

b. Name: __________________________ Relationship: __________________ Ph. Number ( )________________

Address: __________________________ City: State: Zip:

Work Ph. # (____) ______________ Cell Ph. # (____) ________________

24. Does student participate in any of the following programs? (Check all that apply. Information is confidential.)

Special Education _____ I&RS PIRT Speech _____ Basic Skills_____ Counseling _____

Free/Reduced Lunch ____ Limited English (ESL) _____ Gifted & Talented ______

If student is Special Education classified, contact the Office of Supervisor of Pupil Personnel Services at (609) 267-9099

25. If student participates in instrumental music (band or orchestra), specify instrument played: ______________________

26. Has student been previously retained? No____ Yes _____ (If yes) Grade

27. Does student have health insurance? No____ Yes _____ (If yes) Insurance Carrier Name ___________

Residence Information (all information is confidential)

28. Did you establish residence in Lumberton by:

Purchasing _____ Renting _____ Living with a friend/relative ______ Living in a motel/hotel _____

29. Are you homeless? No _____ Yes _____

30. Military Connected Indicator: Not military connected – student is not military connected

Active Duty – dependent of a member of the Active Duty Forces

(Full Time: Army, Navy, Air Force, Marine Corps or Coast Guard)

PLEASE NOTE: Students registered in the two weeks prior to the start of the school year will not receive transportation services until the second full week of school.