Pine Hill School Registration

Pine Hill School Registration
Thank you for registering your child at Pine Hill 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.

Pine Hill School
10 Pine Hill Lane
Sherborn, MA 01770
508-655-0630
In addition to this registration packet, the following documents are necessary for the process of enrollment to begin:

a. A deed, mortgage, rental agreement, or signed purchase & sales agreement. The purchase and sales agreement must be completed within 60 days or the student will be withdrawn from SCHOOL NAME.

- A letter from a landlord or relative is NOT an acceptable item of proof.
- If you are not going to be in your residence by the first day of school, you will need to gain permission from the Superintendent's Office before you can register your student. You will also need to complete the Non Resident Registration Form and return it to the Superintendent's Office.)

b. One of the following is also required:

-Current original gas bill
-Current original oil bill
-Current original electric bill
-Current bank statement, showing Dover/Sherborn address
-PLEASE NOTE: A telephone bill is NOT an acceptable item of proof

c. Custodial Agreement pertaining to the student, if applicable.

d. An up-to-date physical and immunization record. The school nurse will email you
a request for additional information at a later date.

e. Proof of vision screening from student’s pediatrician

f. Proof of Lead Screening (for entering kindergarteners)

g. Student’s birth certificate

h. Previous school records (if applicable)

i. A signed release of access to any additional records/information deemed necessary to the acceptance process. Please arrange for your child’s official school records to be forwarded to the Guidance Office prior to the registration appointment. Please ask the school or schools to include both academic and disciplinary records, including the school’s address, a phone number and the name of the appropriate school contact (such as Principal, Assistant Principal or School Counselor).

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 Sherborn.
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
Format: (000) 000-0000.
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?
What is the student's race?
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
School Name
School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
- Cell Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Home Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Is the parent 1/legal guardian address the same as the student's?
- Please enter the address for Parent/Legal Guardian 1.
- Name
  
  First NameLast Name
- Employer
- Occupation
- Work Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Cell Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Home Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Is the parent 2/legal guardian address the same as the student's?
- 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.Format: (000) 000-0000.
- Alternate Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- 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.Format: (000) 000-0000.
- Alternate Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- 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.Format: (000) 000-0000.
- Alternate Phone
  Please enter a valid phone number.Format: (000) 000-0000.

Extended Day Program

The Sherborn Extended Day Program is housed at Pine Hill School. Information on the program and registration is available at https://www.doversherborn.org/page.cfm?p=935.

List any operations, injuries, hospitalization or prolonged illness and provide dates.
List any past or current mental health concerns.
Recommended Physical Activity:
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.
Please print and fill out this form if you are interested in volunteering in school.

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 10 Pine Hill Lane in Sherborn.
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

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Physical Exam and Immunization Record From Your Doctor

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Vision Screening (including stereopsis)

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Lead Screening (for entering kindergarteners only)

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Previous School Records (if applicable)

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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 Pine Hill 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
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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 Pine Hill.
Email
example@example.com
Should be Empty:

Pine Hill 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

4. In what language(s) would your family prefer to receive written communication from the school?

Required Forms