Danbury Public Schools

Completed Form

Form Verification

Student Information

New Student Information

Place of Birth

Ethnicity and Race Report

This form is to be filled out by the student's parents or guardians, and both questions MUST be answered. Part A asks about the student's ethnicity and Part B asks about the student's race.

Part A - Ethnicity

Part B - Race

l American Indian or Alaskan 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 a community attachment. l Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. l Black or African American: A person having origins in any of the black racial groups in Africa. l Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

l White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Choose one or more:

Are you applying for the 2022-2023 academic school year? Yes

Please click on the following link to determine enrolling school. https://sites.google.com/a/danbury.k12.ct.us/dps_transportation_department/ First Name Bella

Middle Name Joylynn

Last Name Rogers

Suffix

Gender Female

Date of Birth 5/29/2011

Enrolling Grade 6

Enrolling School Broadview Middle School

Home/Residential Information

Primary Phone 203-***-****

Address 89 Hospital Ave

Apt / Unit / Ste

City Danbury

State Connecticut

Zip 05810

Is the student's mailing address different than the physical address listed above?

No

Country of Birth United States of America

State of Birth Connecticut

City of Birth Danbury

Is the student Hispanic / Latino?

No, not Hispanic/Latino

Race(s) White

Family Information

Parent/Guardian Information

[X] American Indian or Alaskan Native

[ ] Asian

[ ] Black or African American

[ ] Native Hawaiian or other Pacific Islander

Home Language Survey

What is the primary language used in the home, regardless of language spoken by student?

English

What is the language most often spoken by the student? English

What is the language the student first acquired?

English

Military Family Status

Active duty members of the uniformed service, National Guard or Reserve on active duty orders, members or veterans who are medically discharged or retired within one year or members who have died on active duty.

Is your student a member of a military family as defined above?

No

Previous School Information

Most Recent School Information

Has this student ever attended school before?

Yes

School Name St. Gregory the great

City Danbury

State Connecticut

Zip 06810

Grade Last Completed 5

Special Education Services

Has your child received special education services? No

Student primarily lives with

Mother Only

If separated or divorced, do you have LEGAL custody of this child? N/A

If separated or divorced, is the non-custodial parent authorized to pick-up this child? N/A

Parent/Guardian 1

First Name Stacy

Last Name Rogers

Relationship to Student Mother

Siblings

Emergency Contact Information

Please list emergency contacts other than parents/guardians listed on previous page. Lives at student's physical address? (Listed on student page) Yes

Primary Phone 203-***-****

Cell Phone/Day Phone

Email Address ad4dxy@r.postjobfree.com

[ ] Check if this Parent/Guardian has no email

address.

Employer Danbury Petroleum corporation

Work Phone 203-***-****

Parent/Guardian 2

First Name

Last Name

Relationship to Student

Lives at student's physical address? (Listed on student page) Primary Phone

Cell Phone/Day Phone

Email Address

[ ] Check if this Parent/Guardian has no email

address.

Employer

Work Phone

Other Parent/Guardian

First Name

Last Name

Relationship to Student

Lives at student's physical address? (Listed on student page) Primary Phone

Cell Phone/Day Phone

Email Address

[ ] Check if this Parent/Guardian has no email

address.

Employer

Work Phone

How many school aged siblings does the student have? 0

Contact #1

First Name Linda

Last Name Anilosky

Student's Medical Information

Health History

Agreements

Relationship to Student Grandmother

Phone Type Cell

Phone 203-***-****

Contact #2

First Name Jennifer

Last Name Pinto

Relationship to Student Friend

Phone Type Cell

Phone 203-***-****

Contact #3

First Name

Last Name

Relationship to Student

Phone Type

Phone

Contact #4

First Name

Last Name

Relationship to Student

Phone Type

Phone

Does the student have any allergies?

No

Does the student have any other medical conditions? No

SBHC Permission Form

Please read the SBHC Permission Form.

Health Assessment Record

Please read the Health Assessment Record.

Registration Medical Information

Please read the Registration Medical Information.

I have read and agree to the terms of the policy.

Yes

I have read and agree to the terms of the policy.

Yes

Electronic Signature

The electronic signature and all of its related fields replaces a handwritten signature on paper and is legally binding. I affirm that the information provided is true, correct and complete, to the best of my knowledge and belief. This electronic signature and its related fields are treated like a handwritten signature on a paper form. Parent/Guardian Signature

Transfer of Records

Please read the Request for Transfer of Records.

Landlord Verification Form

Please read the Landlord Verification Form.

Tylenol Permission Form

Please read the Tylenol Permission Form.

Photo/Video Release

Please read the Photo/Video Release Policy.

I have read and agree to the terms of the policy.

Yes

I have read and agree to the terms of the policy.

Yes

I have read and agree to the terms of the policy.

Yes

I have read and agree to the terms of the policy.

Yes

I have read and agree to the terms of the policy.

Yes

I Agree Yes

Electronic Signature Stacy Rogers

Today's Date 07/26/2022

Contact this candidate