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. 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
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
  Date
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
  Date
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
  Date
- 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?*
- 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.
- 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.
- 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.
- 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.
- 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.

Language Survey
Massachusetts is home to speakers of many different languages. This Language Survey helps us learn about your child’s English language skills and provide support to your child if necessary to help them learn English. Please answer the questions below. If your response to any of the questions in SECTION 1 is a language other than English, the school district will give your child a test to see if they may benefit from English language support.
If you need help completing this form, please ask for assistance.
Student Name

First NameMiddle NameLast Name
Grade
Date Of Birth

MonthDayYear
Date
Name of Parent/Guardian #1:
Name of Parent/Guardian #2:
SECTION 1:

These questions will help the school identify students who may need English language supports. If your response to any question 1-3 is a language other than English, your child will be tested on their use and understanding of English to determine if English language supports are needed.
1: Please list the language(s) that parents and/or primary caregivers use to communicate with your child at home.
2: Please list the language(s) that your child currently uses to communicate with others.
3: Please list the language(s) your child first understood and used to communicate.
SECTION 2: Interpretation and Translation Services

This section will let the school know if you, the parents/guardians, need an interpreter or documents translated.

This section is for informational purposes only and is not used to identify if your child needs support to learn English.
4: In what language(s) would your family prefer to receive written communication from the school?
Parent/Guardian # 1:
Parent/Guardian # 2:
5: Would you prefer for the school to arrange for an interpreter to be available to you free of charge during meetings and phone calls with the school about your child (including American Sign Language or other types of sign language)?

YesNo
If yes, in which language(s)?
SECTION 3 [Optional]: Prior Education
This section will provide the school with background information about your student and their prior education.
This section is optional and is not used to identify if your child needs support to learn English.
6: Please list the name and location of the last school your child attended.

School NameCity/TownCountry
7: How many years has your child attended school in the United States? (beginning with kindergarten)
Please list the date your child first started school in the United States, if known (mm/yyyy):

MonthDayYear
Date
8: Has your child ever attended school outside of the United States?

YesNoNot Sure
If yes, for how many years?
In what language(s) did your child learn while attending school outside of the United States?
What is the last grade your child was enrolled in or completed?
9: Has your child ever received support to improve their English in United States schools?

YesNoNot Sure
10: Is there anything else you think is important for the school to know about your child? (for example, special interests, talents, or concerns you have about your child’s experience in school?)
Parent/Guardian Name:
Parent/Guardian Signature:

Clear
Date (mm/dd/yyyy):

MonthDayYear
Date

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:
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.
Should be Empty:

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

Language Survey

Required Forms