Byron-Bergen Central School District Central Student Registration 6917 W. Bergen Rd., Bergen, NY 14416 Phone (585) 494-1220 ext. 1004 Fax (585) 494-2613

Registration Procedures for New Students Grades 6-12

Welcome to the Byron-Bergen Central School District. Parents/legal guardians will register all school-aged children in Central Registration (located in the District Office).

In addition to the forms that follow this cover page, the District requests the following information:

Proof of a Student’s Address (fill out the Residency Questionnaire on pg. 2)

Some examples include a lease or mortgage statement, recent utility bill, bank statement, or pay stub. Please contact the registration office for other examples of acceptable proof.

Documentation of Age

Some examples include an original birth certificate, record of baptism, passport. Please contact the registration office for other examples of acceptable proof.

Record of Immunizations, Health Records, Dental Exam

Custody / Guardianship / Adoption documents, if applicable

Contact the registration office at (585) 494-1220 ext. 1004 if you have any questions. Office hours: 7:30 a.m. to 3:30 p.m. (M-Th) and 7:30 a.m. to 3:00 p.m. (F) Summer hours: 7:30 a.m. to 1:30 p.m. (M-Th) and 7:30 a.m. to 1:00 p.m. (F)

These documents have been revised to comply with the Amendment of the Regulations of the Commissioner of Education (Subdivision (y) of section 100.2) as adopted by the Board of Regents on December 16, 2014.

Complaints concerning enrollment and registration can be submitted to the OAG by mail to 120 Broadway, 23rd Floor, New York, NY 10271, by phone to (212) 416-8250, or by email to civil.rights@ag.ny.gov.

Byron-Bergen Central School District 6917 W. Bergen Rd., Bergen, NY 14416 Phone (585) 494-1220 Fax (585) 494-2613

ENROLLMENT FORM - RESIDENCY QUESTIONNAIRE

Name of LEA:

Name of School:

Byron-Bergen Central School District	

Byron Bergen Central School District	

Name of Student:
Last	First	Middle

Gender: � Male	Date of Birth: 	 /	 /	
� Female	Month Day	Year � Non-Binary

Current Address:

Grade: 	           ID#: 	

(preschool-12)	(optional)

Phone: 	

The answer you give below will help the District determine what services your child may be able to receive under the McKinney-Vento Act.

Where is the student currently living? (Please check one box.)

In permanent housing

Temporary living situation:

In a shelter

With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as “doubled-up”)
In a hotel/motel

In a car, park, bus, train, or campsite

Other temporary living Situation (Please Describe): ___________________________________

Address resided at during loss of housing ____________________________________________________

Print name of Parent, Guardian, or
		
Student (for unaccompanied homeless youth)

Signature of Parent, Guardian, or
		
Student (for unaccompanied homeless youth)

Date

BYRON-BERGEN CENTRAL SCHOOL DISTRICT Central Registration Office
6917 West Bergen Rd, Bergen, NY 14416 Phone (585) 494-1220, ext. 1004 Fax (585) 494-2613 kbrown@bbschools.org

AUTHORIZATION FOR RELEASE OF INFORMATION (Please fax, mail, or email the student records to the address above)

Date: ________________

__________________________________________ (Name of school student(s) will be transferring from)

__________________________________________ (Address)

__________________________________________ (City, State, Zip)

Phone __________________ Fax ________________ Email ________________________________

I/we authorize the release/exchange ofinformation between the Byron-Bergen Central School District and the above agency for the following student(s):

Student: _______________________________

Student: _______________________________

Student: _______________________________

Student: _______________________________

Student: _______________________________

DOB: ___________

DOB: ___________

DOB: ___________

DOB: ___________

DOB: ___________

Grade: _____

Grade: _____

Grade: _____

Grade: _____

Grade: _____

Permanent Record Information

Including, but not limited to, birth certificate, social security # (optional), most recent report card, all standardized testing, any state testing, high school transcript.

Health Record Information

Including, but not limited to, Hepatitis B verification, most recent immunizations, last physical exam.

Confidential Reports
Including, but not limited to CPSE/CSE records, 504 records, psychological testing, all/any related service information (OT, PT, Speech), outside evaluations.

Signature of Legal Guardian/Parent: ________________________________________

Relationship to Student(s): ___________________________ Date Signed: _________

Witness & Requesting Officer: ___________________________________, Residency Clerk

Byron-Bergen Central School District 6917 W. Bergen Rd., Bergen, NY 14416 Phone (585) 494-1220 Fax (585) 494-2613

Student Racial and Ethnic Identification

To the Parent/Guardian: The BYRON-BERGEN CENTRAL SCHOOL DISTRICT has an Administrative Regulation which requires the collection and recording of the ethnicidentity of students in the BYRON-BERGEN CENTRAL SCHOOL DISTRICT in accordance with the Federal categories and definitions. The information will be used to:

•	Report information to the State and Federal Education Departments.

•	Plan educational programs and make sure that they are readily available to all students.

•	Study the movement of students in different ethnic groups as they move from school to school. •	Analyze differences in academic performance, attendance, and completion of school.

We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions on the back of this page. Put a check () in the box for the category or categories which best describes your child. The BYRON-BERGEN CENTRAL SCHOOL DISTRICT understands the sensitive nature of this information and wishes to assure you that it will be kept secure and confidential in accordance with all State and Federal student privacy laws and regulations. If the information requested is not provided on this form on behalf of your child, a Student Records Officer from the school or district will be required to identify the group to which the student appears to belong, identifies with, or is regarded in the community as belonging. Thank you for your cooperation.

CONFIDENTIALITY PROCEDURES and REGULATIONS

To School Staff: This form will be filed in the student's permanent record as confidential information.

To the Parent/Guardian: The information which you have provided on this form is confidential. It is protected by the Confidentiality Regulations cited below.

The Family Educational Rights and Privacy Act (1974) prohibits unauthorized access to student records and unauthorized release of any student record information identifiable by either student name or student identification number.

Please complete this form and return the form to the Main Office.

Byron-Bergen Central School District 6917 W. Bergen Rd., Bergen, NY 14416
Phone (585) 494-1220 Fax (585) 494-2613

Student Racial and Ethnic Identification

All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.

Byron-Bergen Central School (please check):

ELEMENTARY SCHOOL (Pre-K-5)	JR. HIGH SCHOOL (6-8)	SR.HIGH SCHOOL (9-12)

School District Student Identification Number:	Date of Birth (Month/Day/Year): /	/

Student Name (Last, First, Middle):	Grade Level:

DIRECTIONS TO PARENT/GUARDIAN

PLEASE ANSWER QUESTIONS (1) and (2). PLEASE READ THEM BEFORE YOU RESPOND. For question (1), check () the box that best describes your child. Check () only ONE box.

1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.

Yes, Hispanic

No, not Hispanic

2. Select one or more races from the following five racial groups.

For question (2) check () all groups that apply to your child. Check () at least ONE box.

AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community recognition.

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.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

BLACK: A person having origins in any of the black racial groups of Africa.

WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

_____________________________________________________ Signature of Parent/Guardian

____________________________ Date

Relationship to Student (please check one box below):

Mother	Father	Guardian	Other (specify): ______________________________________

See reverse for important message to Parents/Guardians and Confidentiality Procedures and Regulations.

�Non-Binary

Byron-Bergen Central School District 6917 W. Bergen Rd., Bergen, NY 14416 Phone (585) 494-1220 Fax (585) 494-2613

Student: _________________________ Last Name

__________________________ First Name

____________________ Middle

� Male	�Female	�Non-Binary	Birthdate _____________
-----------------------------------------------------------------------------------------------------------------------------------------------------

Student resides with: � Mother	�Father �Group Home Contact	� Legal Guardian

� Step Mother	� Step Father	�Foster Parent �Other - If other, please specify: _____________________

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PRIMARY - Parent /Legal Guardian #1:______________________________________________________________ � Male �Female	�Non-Binary	�Not Specified	--	�Mr.	�Mrs.	�Ms.	� Miss	� Dr.

Relationship to Student: � Mother	�Father �Group Home Contact	� Legal Guardian

� Step Mother	� Step Father	�Foster Parent �Other___________________

Physical Address: ______________________________________________________________ County:______________

Mailing Address (if different from physical address) _______________________________________________________

Telephone Numbers: (Home) _______________________________ (Cell) ______________________________________

Email Address: ____________________________________________________________

Employer: __________________________________ (Work Phone Number) _________________________

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Parent/Legal Guardian #2:_________________________________________________________________________ � Male �Female	�Non-Binary	�Not Specified	--	�Mr.	�Mrs.	�Ms.	� Miss	� Dr.

Relationship to Student: � Mother	�Father �Group Home Contact	� Legal Guardian

� Step Mother	� Step Father	�Foster Parent �Other___________________

Physical Address: __________________________________________________________________________________

Mailing Address (if different from Physical Address):____________________________________________________

Telephone Numbers: (Home) ______________________________ (Cell) ______________________________________

Email Address: ___________________________________________________________

Employer: ____________________________________ (Work Phone Number) _______________________

Child’s sisters, brothers, and other persons living in the home:

Name

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

Relationship

_____________________

_____________________

_____________________

_____________________

_____________________

_____________________

_____________________

Date of Birth

__________________

__________________

__________________

__________________

__________________

__________________

__________________

Grade

________________

________________

________________

________________

________________

________________

________________

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INSTANT CONNECT (Electronic Phone Messaging): The Byron-Bergen Central School District uses an electronic phone messaging system to contact families by phone of school closings, emergency notifications and event reminders. In the spaces below, please provide the phone number(s) you would like to receive calls at.

1. _________________________________________ (Name)	(Phone Number)

2. ________________________________________________ (Name)	(Phone Number)

3. __________________________________________________ (Name)	(Phone Number)

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EMERGENCY CONTACT INFORMATION:
In the event of an emergency and the parent or guardian cannot be reached, I authorize the transport of my child to the nearest Emergency First Aid Station by ambulance, if necessary. I realize that the school district cannot assume responsibility for the payment of medical fees or expenses incurred. I authorize the School Nurse to obtain immunization, physical examination, injury, and/or illness information from my child’s Physician.

_________________________________________________________________________________________________ Signature of Parent/Guardian	Date

If necessary, I authorize the school to call:

_________________________________________________________________________________________________ Family Physician	Address	Phone #

Preferred Hospital __________________________________________________________________________________ Hospital Name                                          Address                                    Phone #

Family Dentist _____________________________________________________________________________________ Name                                                         Address                                    Phone #

If my child has to be taken home because of minor illness and the parent or guardian cannot be reached, please contact:

Emergency name contact phone number(s)

1._______________________________________________________________________________________________ Name	Relationship to Student	Phone Number
 Male	Female	Non-Binary	Not Specified

2._______________________________________________________________________________________________ Name	Relationship to Student	Phone Number
 Male	Female	Non-Binary	Not Specified

3._______________________________________________________________________________________________ Name	Relationship to Student	Phone Number
 Male	Female	Non-Binary	Not Specified

4._______________________________________________________________________________________________ Name	Relationship to Student	Phone Number
 Male	Female	Non-Binary	Not Specified

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Media Release

Periodically district staff writes feature articles or news stories on the students, staff, or programs within our district. It is not unusual for photographs and/or video clips of our students to accompany these articles and may be included in print newsletters, eNewsletters, website features, or social media.

For your child’s safety, minors’ full names do not accompany photographs on the website or social media. Exceptions include announcing the valedictorian/salutatorian and are not posted without specific parent/guardian permission.

I give permission for my child, _______________________________________, to be interviewed, photographed, and/or videotaped by faculty, staff, or outside news media representatives for press or media purposes as indicated above.

_________________________________________________________________________________________________ Parent/Guardian (Print Name)	Parent/Guardian (Signature)

•	If opting out please fill out a Media DO NOT Release form, available in District Office

I attest that the information completed by me on this form is current, true, and accurate.

Signature of Parent/Guardian
	_________________

Date	

CUSTODY DISCLOSURE FORM

The Registration Office is responsible for registration, not determining which parent or guardian may check a child in/out of school, etc. If custodial or guardianship issues exist when you register your child in the Byron-Bergen Central School District, it is your responsibility to provide custodial documentation to the Registration Office and a copy will be forwarded to your child’s school principal.

Please inform your child’s school of changes in custodial arrangements

Information of Rights of Parent from the Family Education rights and Privacy Act (FERPA) An educational agency or institution shall give full rights under the Act to either parent, unless the agency or institution has been provided with evidence that there is a court order, State statute, or legally binding document relating to such matters as divorce, separation or custody that specifically revokes these rights. (Authority: 20 U.S.C. 1232g)

Please check the current custody/guardianship arrangement:

 	Parents/Guardians are together residing at the same residence

 	Single parent (father and mother ARE listed on the birth certificate)

 	Single parent (i.e. father IS NOT listed on the birth certificate)

 	Parents/Guardians divorced/separated – Joint Custody

 	Parents/Guardians divorced/separated – Sole Custody

 	Parents have never been married and no legal custody papers

 	Custody/Guardianship is transferred by courts

 	Restricted pickup (legal documentation must be provided)

 	Student is emancipated – (legal documentation must be provided)

Please check all that apply:

 	I have disclosed my current custody/guardianship arrangement

 	I have attached a copy of those pages of the legal current court documents that describe custody arrangements

 	No legal documents that describe custody arrangements exist

 	I understand that it is my responsibility to update my child’s school of changes in custody

Students Legal Name (Please Print)	Last	First	Middle

Parent/Guardian Signature	Date

To Be Filled Out By The Parent:

Medical History Form

Student Name: ___________________________________	Date: _______________________

YES

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

NO

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

_______

Is there any history of heart disease?________________________________

Are there any congenital defects (heart, lungs, kidneys)? _______________

Has your child ever had a hernia? __________________________________

Has your child ever been seriously ill? Hospitalized? (give dates) __________

Has your child ever dislocated a knee or any other joint? ________________

Has your child ever had any broken bones? __________________________

Has your child had any injuries within the past year? ___________________

Any dental prosthesis? (braces, false teeth, capped, or loose teeth) _____________

Does your child have any allergies? ________________________________

Is your child presently taking any medication? (including inhalers) ___________

My child has permission to see the school physician

If applicable, please complete the following:

My child has the following condition which requires special handling: __________________________________________

Are there any hearing difficulties? _____________________________________________________________________

Does your child have tubes in his/her ears? ______________________________________________________________

Does your child wear glasses? ________________________________________________________________________

Are there any eye or visual difficulties? _________________________________________________________________

PARENT SIGNATURE ______________________________________________

Please have both the “Health Appraisal Form” and the
“Medical History Form” completed and return both to the Health Office at school.

Byron-Bergen Central School Medication Administration Request

Dispensing medication in school is contrary to statutory regulations under the Nurse Practice Act and New York State Education Law. We realize, however, that it is sometimes necessary for a student to take internal medication during school hours. Certain requirements MUST be met for the administration of medication in school.

1. A written request from the physician indicating the frequency and dosage of the prescribed medication.
2. A written request from the parent to administer the medication
3. Medication must be in the original and properly labeled container. (Request a separate container for school use if necessary.)
4. Medication must be delivered to school by the parent/guardian. Should problems arise, parents should contact the school nurse for assistance.

To Be Completed by the Physician

_________________________________ is under my care and it is necessary that he/she be given the following medication during school hours.

Diagnosis: __________________________________________________________________

Medication: _________________________________________________________________

Dosage: __________________________________ Time: ____________________________

Possible Reactions: ___________________________________________________________

Date: _________________ Physician’s Signature: __________________________________

To Be Completed by the Parent/Guardian

I hereby request that my child, ______________________________ be given the medication as prescribed by his/her physician.

Date: _________________ Parent/Guardian Signature: _______________________________

MEDICATION REQUEST MUST BE RENEWED YEARLY FOR LONG TERM MEDICATION

	Byron-Bergen Central School

(
	Please read, sign, and return page 2
	)

Instructional Computer Network- Acceptable Use Policy Amended 5/27/10

The Board of Education is committed to the development and establishment of a quality,equitable, and cost-effective computer network. The purpose of the network shall be for the advancement and promotion of learning and teaching, and administration and management purposes.

The network will provide a forum for learning various software applications and will significantly enhance educational experiences and provide statewide, national, and global communications opportunities for staff and students.

The District has established rules and regulations governing the use and security of the District’s computer network. Failure to comply with District policy and regulations for the use of the network may result in suspension and/or revocation of computer access. Additionally, student violations may result in discipline up to and including suspension. Staff violations may also result in discipline up to and including dismissal.

Prohibitions

The following is a list of prohibited actions concerning use of the District’s computer network. Violation of any of these prohibitions may result in discipline or other appropriate penalty, including suspension or revocation of a user’s access to the District’s system.
a.	There must be no sharing of passwords without written permission from the teacher/administrator or District Coordinator, as appropriate.
b.	Transmission of material, information or software in violation of any District policy or regulation, local, state, or federal law or regulation is prohibited. c.	No personal software or disks may be uploaded on to the District’s computer and/or network.
d.	Attempts to read, delete, copy, or modify the electronic mail of other system users is prohibited, as is deliberate interference with the ability of other system users to send/receive electronic mail. Forgery or attempted forgery of electronic mail messages is prohibited.
e.	System users shall not engage in or encourage activities prohibited by District policy, State or Federal law.
f.	Attempts by a user to log on to the District’s system in the name of another individual, with or without the individual’s password, is prohibited.
g.	The use of software or hardware to circumvent security protocols, enter or alter District records, or destroy or impair computer use in the District is prohibited.
h.	Copy or install software that is not authorized by proper licensing.

Privacy Rights
Staff data files and electronic storage areas shall remain District property, subject to District control and inspection. The IT Support Specialist II/Coordinator of Computer Instruction may access all such files and communications with prior notice to ensure system integrity and that users are complying with requirements of this policy and accompanying regulations. Staff should NOT expect that information stored on the District computer system will be private, including but not limited to staff email and websites visited.

Internet
Byron-Bergen Central School District DOES NOT HAVE CONTROL OF THE INFORMATION ON THE INTERNET. Some sites accessible via the Internet may contain material that is inappropriate for educational use in a PreK-12 setting. The District does not condone the use of such materials and will not permit usage of such in the school environment. The District also denies any responsibility for the accuracy or quality of information obtained through its Internet accounts.

Acceptable Uses
a.	Use consistent with the mission of the Byron-Bergen Central School District.
b.	Use that encourages efficient, cooperative methods to perform the user’s job duties or educational tasks. c.	Use in support of research and education.
d.	To provide resources and promote collaborative projects.

Unacceptable Uses
a.	Use of technology resources for a commercial, political, or as a profit-making enterprise.
b.	 Accessing or distributing inappropriate material; i.e., obscene, abusive, threatening, harassing (religious, sexual, racial), or anymaterial specificallyprohibited by Federal, State, or local law.
c.	Attempt to illegally access files, data, or accounts.
d.	Activities which interfere with student and staff access to network resources. e.	Working (or attempting to work) from network accounts not assigned to you. f.	Sharing your password or account with others.
g.	Deliberately or intentionally damaging hardware or software.
h.	Use of technology resources for social networking, on-line shopping, or other non-school related uses.

Other
a.	Users must comply with all existing District policies as they may be interpreted to apply to technology resources, including, but not limited to the following: Student Conduct and Discipline, Copyright, Selection Policy, and Sexual Harassment.
b.	Network Security Protocols - Changing Passwords: All staff that has an account on the District’s computer network is required to change his/her password at announced times and dates. Staff is encouraged to use good password protocols that call for a password to be a random series of numbers, letters, and symbols with some of the elements capitalized.
c.	Users must sign a consent form indicating they are aware of this policy and will abide in accordance with it.

NOTE: Byron-Bergen Central School District’s Acceptable Use Policy is subject to change.

Byron-Bergen Central School Acceptable Use Agreement
Student and Parent Permission Form

Your son/daughter is granted access to the Byron-Bergen computer network. This access includes connection to the Internet, which would connect your child with educational resources all over the world. A student and parent must sign and date an Acceptable Use Agreement.	In accepting an account, your child accepts the responsibility of using the network in an appropriate manner.

As a user of the Byron-Bergen Central School District Computer Network, I have read and agreed to comply with theAcceptable Use Policy.

Student Signature: _____________________________________ Date: _____________________

Student Name (please print): ________________________________________________________

Year of Graduation: __________________________

As parent/legal guardian of the student signing above, I grant permission for my child. I understand that somematerials on the Internet may be objectionable; therefore I agree to accept responsibility for guiding my child, and conveying to him/her appropriate standard for selecting, sharing and/or exploring information and media.

Parent/Guardian Signature: ______________________________ Date: ____________________

Parent/Guardian Name (please print): _________________________________________________

Please complete this form and return to your child’s school.

For School Use Only – DO NOT WRITE below this line

Students must sign each year to renew acknowledgement of Acceptable Use Policy:

Date	Name	Date	Name

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________