Leon M. Goldstein High School for the Sciences

General Information Student

1. Last Name * First Name * MI
2. Home Address * Apt #
3. City * State * NYNJCTPA Zip *
4. OSIS # * Email *

Emergency Contact Information

1. Student »
2. Last Name * First Name * MI
3. Parent/Guardian (Student resides with) »
4. Full Name * Relationship * --- Choose ---MotherFatherBrotherSisterAuntUncleGrandparentGuardianOther
5. Parent's Preferred Language of Communication: Written * Oral *
6. Home Phone # * Work Phone # * Cell Phone # *
   xxx-xxx-xxxx
7. Email Home * Email Work
8. Address * Apt #
9. Borough * BrooklynBronxManhattanQueensStaten Island State * NYNJCTPA Zip *
10. Other Parent/Guardian »
11. Full Name Relationship --- Choose ---MotherFatherBrotherSisterAuntUncleGrandparentGuardianOther
12. Parent's Preferred Language of Communication: Written Oral
13. Home Phone # Work Phone # Cell Phone #
    xxx-xxx-xxxx
14. Email Home Email Work
15. Address Apt #
16. Borough BrooklynBronxManhattanQueensStaten Island State NYNJCTPA Zip
17. List below names of three (3) persons who may be called in case of emergency or if child is sick in school »Please note that your child will be released only to the persons listed below.
18. Full Name * Phone # * Relationship *
19. Full Name * Phone # * Relationship *
20. Full Name * Phone # * Relationship *
21. If there is a person who may NOT HAVE ACCESS to child, please indicate »
22. Full Name Relationship Order of Protection Exists? Yes
23. Health Information »
24. Name of Physician/Clinic * Phone # *
25. Health Alert »
26. 1. Does child have any health conditions that may affect participation in physical activities? * Yes No

27. ---

28. 2. Limitations * 3. Allergies *

29. ---

30. 4. 504 services for the current year? * Yes No

31. ---

32. 5. Previous year? * Yes No

33. ---

34. 6. My Child Has: Private Health Insurance Medicaid No Health Insurance

35. ---

36. 7. If "no Health Insurance" are you willing to share contact info from this form to learn about insurance options? * Yes No

37. ---

38. 8. If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured? *
    
39. Siblings »
40. Last Name First Name
41. School of Attendance

42. ---

43. Last Name First Name
44. School of Attendance

45. ---

46. Last Name First Name
47. School of Attendance

General Information

Consent to be on the Internet

1. I hereby give permission for my child's photograph, artwork, poetry or other work produced in conjunction with a school project, class or extracurricular activity, to be on the Department of Education's World Wide Web (WWW) site and Leon M. Goldstein High School website, in accordance with the policies set forth in the DOE's Internet Acceptable Use Policy. I understand that the information to be posted does not include information from my child's academic, guidance, permanent or cumulative record (i.e. grades or attendance records). I also understand that the information to be posted does not include other personal identifiable information such as my child's address, phone number, or social security number. Yes No

Policies and information

1. 1. I give permission for my child to use e-mail services provided by Leon M. Goldstein High School. Yes No

2. ---

3. 2. I give permission to allow my child to design and publish web pages on the Department of Education Facilities, World Wide Web and/or the Leon M. Goldstein High School website. Yes No

4. ---

5. 3. I want to receive attendance and grade information by e-mail. Yes No If yes, enter email:

6. ---

7. 4. I give permission for my child's photograph, video image or printed image and/or artwork, audio recording, film, photograph, poetry, or other work produced in conjunction with a school project, class or extracurricular activity, to put on the Board of Education's World Wide Web and/or the Leon M. Goldstein High School website, in accordance with the policies set forth in the Board of Education's Internet Acceptable Use Policy. Yes No

8. ---

9. 5. I give permission to Leon M. Goldstein High School to give my name, address, phone number and e-mail address to the Parents' Association of the Leon M. Goldstein High School (the PA) solely for the purpose of allowing me to receive communications from the PA. Yes No

10. ---

11. 6. My child has read,understands, and will abide by the rules and regulations regarding the use and care of computer facilities. My child understands that all rules apply when using computer facilities. My child understands that his/her privileges may be suspended or closed if they violate the provisions of this contract as set forth in the Board of Education's Internet Acceptable Use Policy.
    
    As the parent or guardian of the student named above I state that I have read and accept the responsibility for my son/daughter's actions with regard to his/her use of computers and related facilities provided by the Leon M. Goldstein High School. Yes No

12. ---

13. 7. My child and I have read and understand the English departments Summer reading list. Yes No

14. ---

15. 8. My child and I have read and understand the LMG School Dress Code Yes No

16. ---

17. 9. My child and I have read and understand the Minimum Standards for Participation in Extracurricular Activities. Yes No

1. This is to confirm that all information is truthful and accurate to the best of your knowledge. *
2. I will notify the school in writing of any changes in contact information contained within this document.*
3. Electronic Signature: *