PRHS New Student Registration Form

High School New Student Registration Form

Robin Kohut -- (978) 363-5507 -- kohut@prsd.org
Dear Parent / Guardian,

Welcome to the Pentucket Regional School District. We are looking forward to getting to know your child and your family. Please use this form to complete all necessary paperwork so we may register your child for school. Ask any school front office staff for assistance when completing this paperwork or if you need any translation assistance.

Sincerely,
Pentucket Regional School District

Submitter Full Name *

First Name Last Name
Submitters Email *
example@example.com
Student Information
Student Name *

First Name Middle Name Last Name
Nickname
School Year *
Grade Level *
Gender *
Birth Date *

Month Day Year
Town of Birth *
Military Family
Previous School / Location
Military Family - Students who are children of:
1. Active duty members of the uniformed services, National Guard & Reserve on active duty orders
2. Members or veterans who are medically discharged or retired within one year
3. Members who die on active duty
Mode to School
Mode Home

Siblings Attending Pentucket Regional School District
Sibling #1 Name

First Name Last Name
Sibling #1 Grade Level
Sibling #1 PRSD Enrollment
Sibling #2 Name

First Name Last Name
Sibling #2 Grade Level
Sibling #2 PRSD Enrollment
Sibling #3 Name

First Name Last Name
Sibling #3 Grade Level
Sibling #3 PRSD Enrollment
Sibling #4 Name

First Name Last Name
Sibling #4 Grade Level
Sibling #4 PRSD Enrollment

Primary Contact (Only Parent or Guardian with Legal Custody): STUDENT'S RESIDENCE
Please complete the Primary and Emergency Contact Information below. Parents are responsible for alerting school staff of any court documentation that impacts custodial rights to student records, visitation, etc. Copies of these documents must be provided to the school at enrollment

Legal Custodian is defined as "Parent(s), guardian(s), or person(s) assigned by the court."

Per school policy, your child will not be dismissed to anyone not listed as a contact without explicit permission form a parent / guardian.
Student Lives With: *
Primary Contact Name *

First Name Last Name
Primary Gender *
Primary Relationship: *
Primary Cell Phone *
Please enter a valid phone number.
Primary Home Phone
Please enter a valid phone number.
Primary Work Phone
Please enter a valid phone number.
Primary Email *
example@example.com
Primary Address *

Street Address [& Apartment #]

PO Box if Preferred for Mailings

City State / Province

Postal / Zip Code
Under Massachusetts Law Chapter 76 Section 5, only students who actually reside within the towns of Groveland, West Newbury, and Merrimac may enroll in the Pentucket Regional School District. In order to verify residence within the town, a student enrolling in the Pentucket Regional School District must provide documentation of actual residence. In addition to providing such documentation at the time of initial enrollment, the school administration may request verification at any later time if there is doubt of actual residence.

I understand that it is my obligation to promptly notify the school principal of any changes in the students primary residence (place defined as where child sleeps during 4+ nights per week)

Secondary Contact (Only Parent or Guardian with Legal Custody):
Secondary Contact Name

First Name Last Name
Secondary Gender
Secondary Relationship:
Secondary Cell Phone
Please enter a valid phone number.
Secondary Home Phone
Please enter a valid phone number.
Secondary Work Phone
Please enter a valid phone number.
Secondary Email
example@example.com
Secondary Address

Street Address [& Apartment #]

PO Box if Preferred for Mailings

City State / Province

Postal / Zip Code

Emergency Contact #1 (Not Primary or Secondary):
E Contact #1 Contact Name *

First Name Last Name
E Contact #1 Gender *
E Contact #1 Relationship: *
E Contact #1 Cell Phone *
Please enter a valid phone number.
E Contact #1 Home Phone
Please enter a valid phone number.
E Contact #1 Work Phone
Please enter a valid phone number.
E Contact #1 Email
example@example.com
E Contact #1 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact #2 (Not Primary or Secondary):
E Contact #2 Contact Name

First Name Last Name
E Contact #2 Gender
E Contact #2 Relationship:
E Contact #2 Cell Phone
Please enter a valid phone number.
E Contact #2 Home Phone
Please enter a valid phone number.
E Contact #2 Work Phone
Please enter a valid phone number.
E Contact #2 Email
example@example.com
E Contact #2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Materials Required to be Returned before your student is able to begin classes
1) Residency Validation

Cancel of
(A) Record of Living Arrangement:

Cancel of
(B) Recent Utility Bill

Cancel of
(C) Valid Mass. ID (Front & Back)

Cancel of
2) Release of Records Form

Cancel of
3) Home Language Survey

Cancel of
4) Student Health Information

Cancel of
5) Healthcare Providers Examination

Cancel of
6) Certificate of Immunization

Cancel of
7) Student Birth Certificate

Cancel of
8) Student Photo

Cancel of
9) Any Legal Paperwork pertaining to Child (custody, etc)

Cancel of
9) Any legal paperwork pertaining to the Child (custody, etc) must be delivered to the students attending school front office.

Signature: By digitally signing this form, I certify under penalty of perjury that all the information above is true and accurate. *

Clear
Pentucket Regional School District Office of the Superintendent
22 Main Street, West Newbury, Massachusetts 01985-1897
TEL: (978) 363-2280 / FAX: (978) 363-1165

Justin Bartholomew, Ed.D. [Superintendent]
Brent Conway [Assistant Superintendent]
Catherine Page [IT & Digital Learning Director]
Greg A. Labrecque [Business Manager]
Michael A. Jarvis, Ed.D. [Directory of Supplemental and Intensive Services]
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High School New Student Registration Form

Student Information

Siblings Attending Pentucket Regional School District

Primary Contact (Only Parent or Guardian with Legal Custody): STUDENT'S RESIDENCE

Secondary Contact (Only Parent or Guardian with Legal Custody):

Emergency Contact #1 (Not Primary or Secondary):

Emergency Contact #2 (Not Primary or Secondary):

Materials Required to be Returned before your student is able to begin classes