6.19

PLYMOUTH PUBLIC SCHOOLS

PROOF OF RESIDENCY

1.0 RESIDENCY

1.1 In order to attend Plymouth Public Schools, a student must actually reside in the Town of Plymouth. “Residence” is the place where a person dwells permanently, not temporarily, and is the place that is the center of his or her domestic, social, and civic life. This policy includes student acceptance into the Plymouth Public Schools Vocational Technical Education Programs. Temporary residence in the Town of Plymouth, solely for the purpose of attending a Plymouth public school, shall not be considered residency.

1.2 The residence of a minor child is presumed to be the legal residence of the parent(s) or guardian(s) who have physical custody of the child. Any student 18 years or older may establish a residence apart from his or her parent(s) or guardian(s) for school attendance purposes.

2.0 RESIDENCY VERIFICATION

2.1 Families registering for the Plymouth Public Schools or submitting a change of address must demonstrate Plymouth residency by presenting one document from each of three categories in the following table:

All applicants must present at least one document from each column (A, B, and C) below. No document may be used twice as verification.

A. Verification of PlymouthAddress & SchoolDistrict

B. Verification of CurrentResidency At ThisAddress

C. Verification of Identity

Dated within the past 60 days:

- Letter from approvedgovernment agency

- Payroll stub

- Bank or credit cardstatement

- Copy of Deed OR recordof most recent mortgagepayment.

- Copy of Lease AND recordof most recent rent payment.

- Legal affidavit fromlandlord affirming tenancyAND record of most recentrent payment.

- Section 8 Agreement

A utility bill or work order dated within the past 60 days, including:

- Gas bill

- Oil bill

- Electric bill

- Home telephone bill

- Cable bill

-Valid driver’s license

-Current vehicle registration

-Valid Massachusetts photoidentification card

-Valid passport

Dated within the past year:

-W-2 Form

-Excise (vehicle tax bill

-Property tax bill

Dated within the past 60 days:

-Letter from approvedgovernment agency

-Payroll stub

-Bank or credit cardstatement

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6.19

PLYMOUTH PUBLIC SCHOOLS

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2.2 In order to verify residency, Plymouth Public Schools reserves the right to request additional documents and/or to conduct an investigation. Because residency can change for students and their families during the school year, Plymouth Public Schools may verify residency at any time.

2.3 All new applicants are required to present the required three proofs.

2.4 If you are a tenant at will (“month-to-month”) and do not have a written lease, ask your landlord to complete and sign the Landlord/Shared Tenancies Affidavit, available at the schools or online. This form must be notarized prior to submission.

2.5 The “Proof of Residency” policy does not apply to homeless students and families. Contact the office of Pupil Personnel Services (508-830-4300) for assistance with registering your child. If you are staying in a shelter, bring a letter from the shelter staff stating that you are living there.

Revision: Revision: Information: January 25, 2010 Information: May 3, 2010 Information: February 7, 2011 Discussion: January 25, 2010 Discussion: May 3, 2010 Discussion: February 7, 2011 Adopted: January 25, 2010 Adopted: May 3, 2010 Adopted: February 7, 2011

Plymouth Public Schools Plymouth, Massachusetts

Student Registration Form

School: School Year: 2020-2021

Last Name:

First name:

Middle Name:

Gender: Yr. of Grad.

Grade: Homeroom:

SASID #:

Enrollment Date: Former School/School Address: Has student ever been enrolled in a Massachusetts school? YES NO If YES, where:

Has student ever been enrolled in Plymouth? YES NO If YES, where:

Has student taken Gr. 10 MCAS: Math ELA Science If so, where:

Student’s Mailing Address: Street/P.O. Box Town Zip

Student’s Home Address: Street/P.O. Box Town Zip

Is the student homeless: YES NO Home Telephone Number:

Mother’s Name: Live with: Yes No Mother’s address (if different from “home address”):

Mother’s Place of Work: Mother’s Work/Cell Phone No.: Mother’s Home Phone (if different from “home phone”):

Father’s Name: Live with: Yes No Father’s address (if different from “home address”):

Father’s Place of Work: Father’s Work/Cell Phone No.: Father’s Home Phone (if different from “home phone”):

Mother’s Email: Father’s Email:

Guardian: Mother Father Both Other > May child be dismissed to either parent? YES NO

Name: Relationship: Are there any legal issues or dismissal restrictions that the school should be aware of? YES NO If YES, a copy MUST be on file in the School Office.

Birth Date: City-State-Country of Birth: U.S. Citizen: YES NO(mm/dd/yyyy)

IN AN EMERGENCY, NOTIFY / DISMISS TO: (First) IN AN EMERGENCY, NOTIFY / DISMISS TO: (Third) Name: Name:

Phone: Phone:

Relationship: Relationship:

IN AN EMERGENCY, NOTIFY / DISMISS TO: (Second) IN AN EMERGENCY, NOTIFY / DISMISS TO: (Fourth) Name: Name:

Phone: Phone:

Relationship: Relationship:

Information below is required by the Massachusetts Department of Education (please check each appropriate answer).

Is English the first (native) language of the student? YES NO Ethnicity: Is the student either Hispanic or Latino? Is the student capable of performing ordinary classwork in English? YES NO YES NO If not, what is the child’s primary language (spoken most often at home)?

Race (check one or more below):

Is the student currently on an Individual Education Plan? YES NO White

Is the student currently on a 504 Plan? YES NO Black or African American

Are there any court actions pending against the student? YES NO Pacific Islander

Is the student currently suspended? YES NO American Indian or Alaskan Native

Is the student expelled? YES NO Asian

Signature of Parent/Guardian: Date:

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Note: this form provides information about your child’s health history and health care. This information is confidential and will be maintained in the

student’s school health record. If you do not understand a question or word, please ask for assistance.

First Name: Middle Name: Last Name:

Date of Birth: Place of Birth: Date of Last Physical:

Date of Last Dental Exam:

Primary Language:

Section One: Student Medical History

Does your child have a history of: (Select Yes or No) Diagnosis Yes No Yes No Diagnosis: Yes No

Allergies Headaches/Migraines Tobacco Use

Autism Spectrum Disorder

Respiratory Disorders /Asthma

Attention Deficit/ Hyperactivity Disorder

Other Conditions: Physical/Developmental

Current Medications/ Dose:

Section Two: Student Medical History (Select all that apply)

1. Does your child have a life threatening allergy YES NO a. Allergens:b. Does your child require an Epipen®? YES NO c. Allergist/Phone: /

2. Does your child:a. have asthma? YES NO b. use a maintenance inhaler? YES NO c. use a rescue inhaler? YES NO

3. Does your child have Cancer/Leukemia? YES NO a. Current Status: Under treatment In Remission b. Date of Diagnosis: Last Treatment Date: c. Oncologist/Phone: /

4. Has your child ever had a concussion? YES NO a. Date of Injury:b. Was your child seen by a physician? YES NO c. Was your child cleared to return to school/play/sports? YES NO d. Residual restrictions:

5. Does your child have:a. Insulin Dependent Diabetes? YES NO b. Use an: Insulin pump Pen Inject via syringe Continuous Glucose Monitor c. What type of insulin does your child use? Lantus Novolog Humalog Other: d. Endocrinologist/Phone: / e. Date/Result of last A1C level: /

6. Has your child had any recent fractures? YES NO a. Date/site of injury: / b. Any related restrictions:

7. Does your child have seizure disorder? YES NO a. Date of last seizure:b. Medications:c. Neurologist/Phone: /

Plymouth Public Schools Student Health History

Date:

Note: this form provides information about your child’s health history and health care. This information is confidential and will be maintained in the

student’s school health record. If you do not understand a question or word, please ask for assistance.

Student Name: Student Health History (Page 2)

Section Three: Student Surgical History (Complete as appropriate)

Diagnosis Date Diagnosis Date Diagnosis Date

Appendectomy Ear Tubes Heart Surgery

Tonsillectomy & Adenoidectomy

Adenoidectomy with PE tubes

Other:

Section Four: Student Mental/Behavioral Health/Emotional Concerns (Complete as appropriate) It is well documented that there is a connection between a child’s living environment, mental/emotional health, physical health and ability to succeed academically. Answering the following questions will help the school nurse advocate for your child’s day-to-day needs.

Diagnosis Yes No Hospitalizations

Dates Medications Case Workers/Counsellor

Alcohol Abuse

Anxiety

Depression

Drug Abuse

Mood Disorder

Oppositional Defiant Disorder

Post-Traumatic Stress Disorder

School Phobia

Other:

Do you have any questions or concerns regarding your child’s emotional and/or physical health issues that you would liketo discuss in private with your school nurse? Yes No

How should the nurse contact you to arrange a discussion?

Section Five: Family Health Concerns (Complete as appropriate)

Relationship

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Student’s Siblings

Name Birth Date Name Birth Date

Passive Smoke: Student Exposure to People Who Smoke

Tobacco: Never Yes In the Past

Packs/day:½ 1 2 3 or more

Years of Use: Less than 1 year 1-5yrs 5-10yrs Greater than 10 yrs.

If you answered yes: Smokes Inside Smokes outside only

Smokeless Tobacco (Chewing, Ecigarettes): Never Yes In the Past

Does the individual still use tobacco products? Yes No

Parent/Guardian (please print) Parent/Guardian Signature

Phone: Date:

TRANSPORTATION APPLICATION 2020-2021

For student record keeping, please submit even if your student is not using the bus.

For School Use Only:

Date Received

Stamp FOR GUARANTEED SEATING, PLEASE SUBMIT by June 30, 2020. Date Processed: By:

Entered in computer: By:

The Plymouth School Department requires payment of a bus fee for all students intending to use bus transportation for the 2020-2021 school year under the following guidelines: Massachusetts General Law CH. 71, S. 68, requires that school committees provide free transportation, once daily, to and from school for students in grades K-6 who live two (2) or more miles from their assigned schools. The statute further requires that students not be required to walk more than one (1) mile from their home to their assigned bus stop. Therefore, no bus fee will be charged for students in Grades K-6 residing two (2) or more miles from their assigned school. A BUS FEE WILL BE CHARGED for students in Grades K-6 residing less than two (2) miles from their assigned school, and all students in Grades 7-12, regardless of distance.In order to qualify for the advance payment discount and to guarantee a seat on the bus for your child, payment must be made on or before June 30, 2020. Fees paid after that date will be assessed at the REGULAR FEE RATE. The regular fee rate will be reduced by 50 percent (50%) for students enrolled after February 1st (the mid-year point of the school year). One-way bus passes may be purchased at 50 percent (50%) of the regular fee rate. AM or PM must be noted on application.

REGULAR FEE STRUCTURE REDUCED FEE *Families that are on TANF, eligible for SNAP, or meet Federal Income Eligibility Guidelines may apply for a waiver of fees. Bus applications should still be submitted.

PLEASE NOTE – A Massachusetts Free and Reduced Price School Meals Application MUST be filled out annually at the start of the year.

ADVANCE PAYMENT DISCOUNT RATE

On or before June 30, 2020

REGULAR FEE RATE Applies after June 30, 2020

Reduced/Free Eligible Rate*

For first student rider $100 $125 $00 For second student rider $ 75 $100 $00

For third student rider $ 50 $ 75 $00 Maximum per family $225 $300 $00

All rates subject to change.

Transportation applications are sent home with third-term report cards and are available thereafter at your child’s school. Bus fees are due in full with this application. PAYMENTS ARE NON-REFUNDABLE. Payments may be made by bank check, money order or personal check only. Personal checks returned for insufficient funds will be charged a $25 processing fee in addition to the bus fee.

NO CASH WILL BE ACCEPTED. Please make checks payable to: “TOWN OF PLYMOUTH – BUS FEE.”

APPLICATIONS and FULL PAYMENT SHOULD BE RETURNED TO ONE OF THE SCHOOLS WHERE YOU WILL HAVE A CHILD ATTENDING DURING THE 2020-2021 SCHOOL YEAR, making sure to include the school names where all other children are enrolled. A copy will be scanned to each school. Applications can be mailed to the school during the summer. Please visit http://www.plymouth.k12.ma.us for individual school addresses. Passes will be distributed in the fall.

Please complete one (1) application per family and include all students that will attend Plymouth Public or Charter Schools, even if no payment is due and/or student is not using bus transportation.

Parent/Guardian Name(s): Number of children in family attending Plymouth Schools:

Street Address: Home Phone:

Complete Mailing Address, if different: Cell/work Phone:

Please list names of all students in family, even if no payment is due. Please check one: For School Use Only

Student(s) Name(s) **School in 2020-21**

Grade in 2020-21

Will use bus

Will NOT

use bus

ALTERNATE transportation if not using bus

Elig. Amount Paid

Scanned to other schools

**Please provide school name where each student attends. This application will be scanned to all schools listed. **

PARENT/GUARDIAN SIGNATURE: DATE:

Plymouth Public Schools HOME LANGUAGE SURVEY

Plymouth Public Schools HOME LANGUAGE SURVEY [HAITIAN CREOLE]

Cc: Principal; Guidance Counselor Home Language Survey H:ELL\F-HmLangSrvy-English English Form

Español: Este es un documento importante. Por favor hágalo traducir. Póngase en contado con la escuela de

su niño si usted necesita ayuda. Gracias.

Português: Isto é um documento importante. Por favor mande-o traduzir. Contate a escola da sua criança se

você precisar de ajuda. Obrigado.

Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.

Student Information

F M First Name Middle Name Last Name Gender

Country of Birth Date of Birth (mm/dd/yyyy) Date first enrolled in ANY U.S. school (mm/dd/yyyy)

School Information

______ Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade

Questions for Parents/Guardians

What is the native language(s) of each parent/guardian? (circle one)

(mother / father / guardian)

(mother / father / guardian)

Which language(s) are spoken with your child? (include relatives -grandparents, uncles, aunts,etc. - and caregivers)

seldom / sometimes / often / always

seldom / sometimes / often / always

What language did your child first understand and speak? Which language do you use most with your child?

Which other languages does your child know? (circle all that apply)

speak / read / write

speak / read / write

Which languages does your child use? (circle one)

seldom / sometimes / often / always

seldom / sometimes / often / always

Will you require written information from school in your native language? Y N

Will you require an interpreter/translator at Parent-Teacher meetings? Y N

Parent/Guardian Signature:

X Today’s Date: (mm/dd/yyyy)

TO BE COMPLETED BY QUALIFIED ELL PROGRAM STAFF MEMBER BEFORE PLACEMENT

Date / School

Enrlmnt: ______

Student’s First Name Student’s Family Name Age Birthdate Grade

____ _________ ____

Relationship of Person Completing Survey: Mother Father Guardian Date Student entered the

United States:

Other Specify:

RECOMMENDATION: Signature of ELL Staff Proficiency Testing to determine LEP status and Academic Records Review. Member: Certified/Qualified ELL staff must make this assessment/recommendation.

Sheltered English Immersion FLEP _____________________

Proficient – No Sheltered Immersion Program: Note that this decision must be made with a full assessment of student proficiency based on either local proficiency testing or academic records from the previous school district showing reclassification of student from LEP to

formerly LEP using multiple criteria. Qualified staff must conduct this assessment.

Plymouth Public Schools

Administration Building 11 Lincoln Street

Plymouth, MA 02360

Telephone: 508-830-4300 Fax: 508-746-1873

Web: www.plymouth.k12.ma.us

GARY E. MAESTAS, Ed.D. Superintendent of Schools

CHRISTOPHER S. CAMPBELL, Ed.D.

Assistant Superintendent

Administration and Instruction

PATRICIA FRY

Assistant Superintendent

Human Resources

GARY L. COSTIN, R.S.B.A.

School Business Administrator

Liability Release Form ~ 2020-2021

As a result of a recent school district insurance review, our insurance carrier has recommended that all participants in school sponsored activities that occur outside of the regular classroom have a signed waiver on file. Students will be unable to participate in such activities if a signed Liability Release Form is not on file. I, the undersigned ________________________of _______________________________, my child or ward, Parent, guardian, etc. Student’s name (first and last) a minor, do hereby consent to my child’s participation in voluntary athletic or recreation programs, field trips, or school sponsored activities of the Town or Public School of Plymouth.

I also agree to forever release the Town or Public School of Plymouth, the School Committee, and all their employees, agents, board members, volunteers and any and all individuals and organizations assisting or participating in voluntary athletic or recreation programs, field trips, or school sponsored activities of the Town or Public Schools (“the Releasees”) from any and all claims, rights of action and causes of action that may have arisen in the past, or may arise in the future, directly or indirectly, from personal injuries to my child or property damage resulting from my child’s participation in the Town or Public School of Plymouth voluntary athletic or recreation programs, field trips, or school sponsored activities. I also promise, to indemnify, defend, and hold harmless the Releasees against any and all legal claims and proceedings of any description that may have been asserted in the past, or may be asserted in the future, directly or indirectly, arising from personal injuries to my child or property damage resulting from my child’s participation in the Town or Public School of Plymouth voluntary athletic or recreation programs, field trips, or school sponsored activities. I further affirm that I have read this Consent and Release Form and that I understand the contents of this Form. I understand that my child’s participation in these programs is voluntary and that my child and I are free to choose not to participate in said programs. By signing this Form, I affirm that I have decided to allow my child to participate in the Town or Public School’s athletic or recreation programs, field trips, or school sponsored activities with full knowledge that the Releasees will not be liable to anyone for personal injuries and property damage my child or I may suffer in voluntary Town or Public School athletic or recreation programs, field trips, or school sponsored activities.

Parent Signature:

Parent Printed Name:

(Please print)

Parent or Guardian of:

Grade:

(Please print)

School:

Date:

Massachusetts Parental Notice for One Time Consent to Allow the School District

To Access MassHealth (Medicaid) Benefits

School District Name and Code: Plymouth Public Schools (02390000)

School/District Contact: Christine Freitas Telephone: 508-224-5043

Dear Parent/Guardian:

The purpose of this letter is to ask for your permission (also known as consent) to share information about your child with MassHealth. Local communities in Massachusetts have been approved to receive partial reimbursement from MassHealth for the costs of certain health-related services provided by the district to your child (or children). In order for your community to get back some of the money spent on services, the school district needs to share with MassHealth the following types of information about your child: name; date of birth; gender; type of services provided, when, and by whom; and MassHealth ID.

With your permission, the school district will be able to seek partial reimbursement for services provided by MassHealth, including, among others, a hearing test or eye exam; a school physical; occupational or speech or physical therapy; some school nurse visits; and counseling services with the school social worker or psychologist. Each year, the district will provide you with notification regarding your permission; you do not need to sign a form every year.

The school district cannot share with MassHealth information about your child without your permission. As you consider giving permission, please be advised of the following:

1. The school district cannot require you to sign up for MassHealth in order for your child to receive the health-related and/or special education services to which your child is entitled.

2. The school district cannot require you to pay anything towards the cost of your child’s health-related and/or special education services. This means that the school district cannot require you to pay a co-pay or deductible so that it can charge MassHealth for services provided. The school district can agree to pay the co-pay or deductible if any such cost is expected.

3. If you give the school district permission to share information with and request reimbursement from MassHealth: a. This will not affect your child’s available lifetime coverage or other MassHealth benefit; nor will it in any way

limit your own family’s use of MassHealth benefits outside of school. b. Your permission will not affect your child’s special education services or IEP rights in any way, if your child is

eligible to receive them.

c. Your permission will not lead to any changes in your child’s MassHealth rights; and

d. Your permission will not lead to any risk of losing eligibility for other Medicaid or MassHealth funded programs.

4. If you give permission, you have the right to change your mind and withdraw your permission at any time.

5. If you withdraw your permission or refuse to allow the school district to share your child’s records and information with MassHealth for the purpose of seeking reimbursement for the cost of services, the school district will continue to be responsible for providing your child with the services, at no cost to you.

I have read the notice and understand it. Any questions I had were answered. I give permission to the school district to share with MassHealth records and information concerning my child(ren) and their health-related services, as necessary. I understand that this will help our community seek partial reimbursement of MassHealth covered services.

Parent/Guardian Signature: Date: _________________

Child's Name: Date of Birth: SASID # (for district to add):

Child's Name: Date of Birth: SASID # (for district to add):

Child's Name: Date of Birth: SASID # (for district to add):

Add more children

Massachusetts DESE Mandated Form 28M/13 Revised June 2018