Student Registration Form

* denotes fields that must be completed

* Indicates required field

Student Name (Last, First, Middle Initial) *

Birth Date *

Grade *

Gender *

City/State of Birth *

If born outside of the United States, list United States Entry Date (mm/dd/yy) *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Last School Attended *

Last School Phone Number *

Country of Birth *

If born outside of the United States, list First Entry United States School *

Last School Address *

Line 1

Line 2

City

State

Zip Code

Country

Was the student ever previously registered in the Beverly City School District? *

Yes No

If “Yes”, what was the last grade the student completed in Beverly City School? *

PARENT/GUARDIAN INFORMATION

Student Name *

Note: A copy of custody/guardianship papers MUST be provided to the school to be kept on file. (if applicable

Custody/guardianship papers *

Max file size: 20MB

Mother/Guardian (1) *

Father/Guardian (2) *

Home Address (if different from student address) *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Email *

Home Address (if different from student address) *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Email *

MILITARY CONNECTION:

Please select which answer best matches your child’s current situation *

FAMILY INFORMATION

Student's Name *

Person with whom student resides *

Mother Father Both Other

If Other, Please state who. *

Mother/Guardian (1) Place of Employment *

Father/Guardian (2) Place of Employment *

Phone Number *

Stepmother’s Name (if applicable) *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

OTHER CHILDREN IN FAMILY (Name, Gender & Age) *

Phone Number *

Stepfather’s Name (if applicable) *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

If I move from the above address within the District, I must notify the Registrar’s office immediately & complete a Change of Address form within five days.

Choose Any *

I HEREBY AUTHORIZE BEVERLY CITY SCHOOL TO INVESTIGATE AND CONFIRM ANY STATEMENTS MADE BY ME.

Choose Any *

I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND THAT I WILL ABIDE BY THE POLICY.

RESIDENCY INFORMATION

In accordance with New Jersey state law (N.J.S.A. 18A:38-1 and 18A:7B-12), it is necessary to determine the residence of students entering the school district by answering the following questions:

If Other; please explain *

Mortgage Statement/ Deed/Lease *

Max file size: 20MB

NOTE: A Beverly City School District Affidavit of Residency Form (Renters) or (Owners) need to be completed and notarized as per circumstances.

Completed Beverly City School District Affidavit of Residency Form *

Max file size: 20MB

Are you living in a temporary residence out of necessity because the family lacks a regular or permanent residence of their own? *

Yes No

Check One: *

The family is currently seeking permanent residence in Beverly City The family will be seeking permanent residence in Beverly City The family is NOT seeking a permanent residence in Beverly City at this time

Please print the name of the person with whom you are staying: *

If yes, last district of permanent residency *

OTHER CHILDREN IN FAMILY (Name, Gender & Age) *

Student's Name *

Parent's Name *

Choose Any *

This statement is made under oath. I am aware that if any of the foregoing statements made in the Affidavit are willfully false, I may be subject to punishment. Additionally, I will be responsible for paying the Beverly City School District annual cost per pupil of $11,775.00 (as of 2016-2017 school year)

ACADEMIC INFORMATION

Student's Name *

PERTINENT HEALTH INFORMATION

Student's Name *

Does your child have any of the following, if yes, please explain:

Allergies (food, medication, etc) *

Diabetes *

Heart Murmur *

Asthma *

Seizure Disorder *

Other *

List any current medications: *

Family Doctor *

Family Doctor Phone Number *

Please upload student shot record *

Max file size: 20MB

Physical Exam Record Form

Registro de Examen Fisico

Please upload Physical Exam Record *

Max file size: 20MB

HEALTHCARE COVERAGE INFORMATION:

Is this student covered by some type of healthcare plan? *

Yes No

Please provide the name of the health care coverage *

EMERGENCY CONTACT
I agree that either one of these emergency contacts may pick up my child from school in the event I cannot be reached.

Name *

Relationship to Student *

Day time Phone Number *

Relationship to Student *

Day time Phone Number *

Please click here to download the needed registrations forms and upload below.

Registration Forms Upload *

Max file size: 20MB

PARENT/GUARDIAN VERIFICATION

Student's Name *

I understand that my child may be tested in Language Arts, Reading, Math, and/or English as a Second Language before he/she is properly placed in a classroom in the Beverly City School District. I have received a copy of the school hours and uniform policy. I understand if any of the required registration documents are missing at time of registration I have 30 Days to provide them. I further attest that all information provided on this registration form is true and accurate and may be investigated by the School Resource Officer or the Beverly City Board of Education.

*It is the responsibility of the parent/guardian to provide any updates or changes to the demographic information
within ten (10) days of such change.

Changes in phone numbers, emergency contacts, etc. must be presented in writing to the Beverly City School.
Changes in residency, guardianship or parent custody must be presented to the

Beverly City School at:
601 Bentley Avenue, Beverly, NJ 08010
Phone – (609)387-2200
This is essential to maintain our emergency data contact base.

Submit

Note about the documents on this site: Most of the documents on this site are PDF (Portable Document Format) documents. You will need to have Adobe Acrobat Reader installed on your computer to view and print them. Please click here to get Acrobat Reader.

If you have any problems downloading or reading the PDF documents on this page please call 609-387-2200 and someone can help you.

American Foundation for the Blind (AFB)

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About Beverly City School

Beverly City School is a Preschool through 8th grade school located in Beverly City, New Jersey.

Contact us by phone

609-387-2200

Contact our Superintendent

Elizabeth Giacobbe, Beverly City School District Superintendent

Elizabeth C. Giacobbe, Ed.D.
egiacobbe@beverlycityschool.org

Location

601 Bentley Avenue,
Beverly City, NJ 08010

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Student Registration Form