Chickering School Registration

Chickering School Registration
Thank you for registering your child at Chickering School. If registering more than one child, please complete a separate form for each. You may save this form at any time. After you complete the form it will automatically be securely submitted to our front office.

Chickering School
29 Cross Street
Dover, MA 02030
508-785-0480
PLEASE NOTE:

In addition to this registration packet, you will also need to turn in the following documentation:
- Birth certificate for your child
- Physical exam report with immunization history for your child
- Proof of vision screening from student’s pediatrician
- Proof of Lead Screening (for entering kindergarteners)
- Previous school records (if applicable)
- Third Party Release Form (only applicable to students entering grades 1-5). This is linked at the end of the registration form.
- Proof of residency for new residents only (utility bill or P&S)

Residency Verification
Name of person completing this form:*

First NameLast Name
I attest, under the pains and penalties of perjury, that the registrant is currently a resident of the Town of Dover.
Relationship to child:*
Mass. General Laws: Section 76, Section 5

Every person shall have a right to attend the public school of the town where he/she resides, subject to the following section: No school committee is required to enroll a person who does not actually reside in the town unless said enrollment is authorized by law or by the school committee. Any person who violates or assists in the violation of this provision may be required to remit full restitution to the town of the improperly attended public schools. No person shall be excluded from or discriminated against in admission to a public school of any town, or in obtaining the advantages, privileges and courses of study of such public school on account of race, color, sex, religion, natural origin or sexual orientation. Amended by St. 1971.c622.c.1: c925, s9A; St. 1993, c.282; St 2004, c.352, s.33

Student Identification
Grade in which you are enrolling this student:*

Student Identification
School Year in which the child will begin attending:
Name of student:*

First NameMiddle NameLast Name
Preferred name:*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Gender*
Date of Birth*

MonthDayYear
Date
City of birth*
State of birth*
Country of birth*
Non-Citizen Visa #
Names of other children in the household

Child 1
Name

First NameLast Name
Date of birth

MonthDayYear
Date

Child 2
Name

First NameLast Name
Date of birth

MonthDayYear
Date

Child 3
Name

First NameLast Name
Date of birth

MonthDayYear
Date

Child 4
Name

First NameLast Name
Date of birth

MonthDayYear
Date

Ethnicity and Race

The Department of Elementary and Secondary Education requires certain demographic data to be collected for each student. Race definitions are below.
Is the student Hispanic or Latino?*

YesNo
What is the student's race?*

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or other Pacific Islander
Ethnicity Definition for Hispanic/Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race.
Race Definitions

White: a person having origins in any of the original peoples of Europe, the Middle East, or North America.
Black or African American: a person having origins in any of the black racial groups of Africa.
Asian: a person having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Previous School Information

Please provide this information so that we may contact your child's previous school if necessary.
Type of school attended*

PublicPrivateDid not previously attend school
School Name
School Phone Number
Please enter a valid phone number.
School Email address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are there any legal/custodial issues that the school should be aware of?*

Parent 1/Legal Guardian Information
Name*

First NameLast Name
Employer
Occupation
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Is the parent 1/legal guardian address the same as the student's?*

YesNo
Please enter the address for Parent/Legal Guardian 1.

Parent 2/Legal Guardian Information
Name

First NameLast Name
Employer
Occupation
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Is the parent 2/legal guardian address the same as the student's?

YesNo
Please enter the address for parent/legal guardian 2.

Emergency Contact Information

In addition to parent or guardian information collected above, we request that you provide at least two additional emergency contacts. These people will only be contacted if a parent or guardian cannot be contacted.

Emergency Contact 1
Name*

First NameLast Name
Relationship to child*
aunt, friend, neighbor, etc.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.

Emergency Contact 2
Name*

First NameLast Name
Relationship to child*
aunt, friend, neighbor, etc.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.

Emergency Contact 3 (optional)
Name

First NameLast Name
Relationship to child
aunt, friend, neighbor, etc.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.

Extended Day Program (DEDA)

The Dover Extended Day Program is housed at Chickering School. Information on the program and registration is available at http://www.doversherborn.org/page.cfm?p=1271.

List any operations, injuries, hospitalization or prolonged illness and provide dates.
List any past or current mental health concerns.
Recommended Physical Activity:*

Full Activity/SportsModified/Restricted
Please explain any activity restrictions
Required Medical Documents
- a copy of your child's most recent physical exam dated at most 12 months before entry into school (for example, if your child is starting school on 9/1/21, the physical submitted must be dated 9/1/20 or later)
- a complete immunization record which must include the following vaccines and testing:
  - DTaP 5 doses
  - Polio 4 doses
  - Hepatitis B 3 doses
  - MMR 2 doses
  - Varicella 2 doses or, a physician-documented case of varicella with date of illness noted
  - Vision testing including stereopsis
  - Lead test for any child entering kindergarten
If your child has not received vaccines due to a medical or religious exemption, please contact the school nurse for further instruction.

CORI Form- Optional

We welcome parents and community members in our schools and we value the opportunity to share school experiences. If you would like to volunteer your time, either in the classroom or on a field trip, please fill out the CORI form.

You should bring this completed form to the main office between 7:15 and 3:00 along with your driver's license for verification.

Required Forms

On this page you have the option of uploading and submitting required forms. If you elect to bring them to school, you should visit the front office between the hours of 7:15 and 3:00. You can find us at 29 Cross Street in Dover.
Required Forms Are:
- Birth certificate for your child
- Physical exam and immunization record from your doctor
- Previous school records (if applicable)
- Third Party Release Form (only applicable to grades 1-5)
- Proof of residency for new residents only (utility bill or P&S)
Birth Certificate for Your Child

Cancelof
Physical Exam and Immunization Record From Your Doctor

Cancelof
Vision Screening (including stereopsis)

Cancelof
Lead Screening (for entering kindergarteners only)

Cancelof
Previous School Records (if applicable)

Cancelof
Third Party Release Form

Applies only to registrants for grades 1-5

By filling out this form, you allow your child's former school to transfer records to Chickering School. You can fill out and submit this form at this link: https://form.jotform.com/210546572722050
Proof of Residency (for new residents only)

such as a utility bill or P&S
Cancelof

You have reached the end of the form. We appreciate your time and patience. We look forward to working with you and your child at Chickering.
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Chickering School Registration

Residency Verification

Student Identification

Early Childhood Education Experience Survey

Student Identification

Names of other children in the household

Ethnicity and Race

Additional Student Questions

Previous School Information

Emergency Contact Information

Student Profile

Permissions

Policies

Student Medical Information

Home Language Information

Required Forms