MS-HS 2023 New Student Registration Form

PRSD Middle - High School
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 submit 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.

All required forms will need to be prepared in the appropriate format in order to complete this submission. Please review the information on the PRSD Student Registration webpage to ensure you have all the required documents before continuing.

Sincerely,
Pentucket Regional School District

ALL Required Fields & Forms Must be Included for Online Submission

Middle School: Amy Costa -- (978) 363-5507 -- acosta@prsd.org
High School Robin Kohut -- (978) 363-5507 -- kohut@prsd.org

Submitter Full Name*

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

First NameMiddle NameLast Name
Nickname
Gender*
Birth Date*

MonthDayYear
Place of Birth*
Military Family*
Previous School / Location*
Military Family - Students who are children of:
1. Active duty member of the uniformed services, National Guard & Reserve on active duty orders
2. Member or veteran who are severely injured and medically discharged or retired for a period of 1 (ONE) year after medical discharge or retirement.
3. Member who died on active duty for a period of 1 (ONE) year after death.
Mode to School*
Mode Home*

Siblings Attending Pentucket Regional School District
Sibling #1 Name

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

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

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

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

Street Address [& Apartment #]

PO Box if Preferred for Mailings

CityState / 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 NameLast Name
Secondary Gender
Secondary Relationship:
Secondary Cell Phone
Please enter a valid phone number.
Secondary Alternate Phone
Please enter a valid phone number.
Secondary Email
example@example.com
Secondary Address

Street Address [& Apartment #]

PO Box if Preferred for Mailings

CityState / Province

Postal / Zip Code

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

First NameLast Name
E Contact #1 Gender*
E Contact #1 Relationship:*
E Contact #1 Cell Phone*
Please enter a valid phone number.
E Contact #1 Alternate Phone
Please enter a valid phone number.

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

First NameLast Name
E Contact #2 Gender
E Contact #2 Relationship:
E Contact #2 Cell Phone
Please enter a valid phone number.
E Contact #2 Alternate Phone
Please enter a valid phone number.

Required Documents

Must be provided before your student is able to begin classes
1) Residency Validation*

[PDF file type ONLY]
Cancelof
(A) Record of Living Arrangement*

[PDF file type ONLY]
Cancelof
(B) Recent Utility Bill*

[PDF file type ONLY]
Cancelof
(C) Valid Mass ID - Front & Back*

[PDF or JPG file type are acceptable]
Cancelof
2) Release of Records Form*

[PDF file type ONLY]
Cancelof
3) Home Language Survey*

[PDF file type ONLY]
Cancelof
4) Student Health Information *

[PDF file type ONLY]
Cancelof
5) Healthcare Providers Examination*

From Health Care Provider [PDF file type ONLY]
Cancelof
6) Certificate of Immunization*

From Health Care Provider [PDF file type ONLY]
Cancelof
7) Student Birth Certificate*

[PDF file type ONLY]
Cancelof
8) Student Photo*

[PDF or JPG file type are acceptable]
Cancelof

9) Any legal paperwork pertaining to the student (custody, etc) should be submitted to the main office of the student's school.

School Year*
Grade Level*

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

Clear
SIGNATURE:
To sign using a mouse: click and hold the mouse button while drawing your signature.
To sign with a touchpad: maintain steady contact on the touchpad with your finger while drawing.

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]

Should be Empty:

PRSD Middle - High School

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)

Required Documents