Registration Form 2024-2025

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Student's Last Name *

Student's First Name *

Student's Age *

Student's Date of Birth *

YYYY

Student's Gender *

Student's Grade (2024-2025) *

Student's Place of Birth (City, State) *

Student's Ethnicity *

Student's Race *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Student's Home Address *

Student's Mailing Address (if different)

Student's Home Phone *

Parent/Guardian 1 (Last Name, First Name) *

Parent/Guardian 1 Home Address *

Parent/Guardian 1 Email Address *

Parent/Guardian 1 Home Phone *

Parent/Guardian 1 Cell Phone *

Parent/Guardian Work Phone *

Parent/Guardian 2 (Last Name, First Name) *

Parent/Guardian 2 Home Address *

Parent/Guardian 2 Email Address *

Parent/Guardian 2 Home Phone *

Parent/Guardian 2 Cell Phone *

Parent /Guardian 2 Work Phone *

Student Lives With *

Parent's Marital Status *

If Divorced, do you have a custody agreement? *

Yes (Please submit pages pertinent to child custody to the Main Office)

N/A

Does your student have a court designated custodial person? (If yes, please submit paperwork to the Main Office) *

Yes

Student's Military Connection *

Not Active Military Connected: Student is a dependent of someone not in the full-time, Active Duty Forces (Army, Navy, Airforce, Marine Corps, Coast Guard).

Active Military Connected: Student is a dependent of a member of the full-time, Active Duty Forces (Army, Navy, Airforce, Marine Corps, Coast Guard or is a dependent of a member on Full-Time National Guard Duty).

National Guard or Reserve Connected: Student is a dependent of a member of the National Guard (not full-time duty) or Reserve Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard).

Unknown: It is unknown whether or not the student is military-connected.

Student's Native Language *

English

Spanish

Other

Parent's Native Language *

English

Spanish

Other

Student's Physician *

Student's Physician Phone Number *

Does your child have insurance? *

Yes

No (NJ Family Care provides free or low cost health insurance for uninsured children and certain low income parents. For more information call 800-701-0710 or visit www.njfamilycare.org to apply.

If yes, Name of Insurance Company

If no health insurance, you may release my name and address to the NJ Family Care Program to contact me about health insurance. Pursuant to 20 U.S.C. 1232g(b)(1) and 34 C.F.R. 99.30(b)

Yes

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Student's previous school attended

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