Hatfield Public Schools
34 School Street
Hatfield, MA 01038
Pupil Data Form
School: _________ Hatfield Elementary School _________Smith Academy
STUDENT INFORMATION:
Date: ____________________________________________
Last Name: ______________________________________________
First Name: ______________________________________________ Home Phone: ______________________________
FULL Middle Name: _______________________________________ Gender: Female ______ Male _____
Date of Birth: __________________________ City or Town of Birth: _____________________________________
State of Birth: __________________________ Country of Birth: _________________________________________
PLEASE NOTE for 1st Grade or Kindergarten Entrance PROVIDE COPY OF BIRTH CERTIFICATE (or bring original with you for copying)
Parent(s) email address: ______________________________________________________________________________________
Home Address: _____________________________________________________________________________________________
# and Street Town Zip
Mailing Address,
If different: ________________________________________________________________________________________________
Child Lives with: Mother/Father ____ Mother ____ Father _____ Other________________________________________
Name / Relationship
Who is: Custodial ____ Non-Custodial ____ Current Documents Provided ___Yes ___ No
NOTE: If there is any pertinent information relating to legal custody of your child, or any cautions/concerns about persons who should not have access to your child, please advise the school principal/office.
School Last Attended: _______________________________________________________ Grade Last Attended: _______________
Address of Prior School: ______________________________________________________________________________________
# Street City State Zip
STUDENT INFORMATION REQUIRED FOR PROVISION TO THE STATE DEPARTMENT OF EDUCATION:
1. Did your child ever attend school anywhere in Massachusetts? _____Yes _____ No
If Yes, please provide.
Name/Location of School(s) _____________________________________________Dates Attended: _________________
2. Race (State Definition: "The general racial category which most clearly reflects the individual's recognition of
of his or her community or with which the individual most identifies.") I invite you to indicate below how you would have
us record your child’s race. Please check any/all that apply. The categories used by the State are:
__ American Indian or Alaskan Native __ Asian __Native Hawaiian or Other Pacific Islander
__ Black or African American __ White __ Hispanic
3. Each school is also required to record the Primary Language Spoken at home.
__English __ Spanish __ Polish __ Other _______________________
4. Immigrant Status: (State Definition - "An indication of whether a student is eligible for the Emergency Immigrant Education
Program. To be eligible for this program, a student must: (1) Not have been born in any State; and (2) Not have completed three
full academic years of school in any state.")
Qualified? _____Yes _____ No
If Yes, a. Country of Origin: __________________________ (State Definition: "…Country from which
immigrant children have emigrated." ~ CONTINUED ON BACK ~
b. First (Native) Language: ___________ (State Definition: "Native Language is the specific
language or dialect first learned by an individual or first used by the parent/guardian with a child.")
5. Migrant Status: (State Definition - "An indication of whether an individual or parent/guardian accompanying
an individual maintains primary employment in one or more agricultural or fishing activities on a seasonal or
other temporary basis and establishes a temporary residence for the purpose of such employment.")
Qualified? _____ Yes _____ No
6. Is this child a State Ward? _____ Yes _____ No
PARENT/GUARDIAN/FAMILY INFORMATION:
____________________________________________________________________________________________________________
Father's Name Address Telephone Number
____________________________________________________________________________________________________________
Employer Address Business Telephone
____________________________________________________________________________________________________________
Mother's Name Address Telephone Number
____________________________________________________________________________________________________________
Employer Address Business Telephone
Siblings: _____________________________________ __________________________________________________________
Name Date of Birth Name Date of Birth
_____________________________________ _________________________________________________________
Name Date of Birth Name Date of Birth
Additional information pertaining to the registration data that you think might be relevant to the school:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I hereby certify that the information provided on this form is true and that in the event of a change of address, I will notify the school principal of said change immediately.
Signature: _________________________________________________________________ Date: ____________________________
TO BE COMPLETED BY SCHOOL PERSONNEL:
Entry Date: ____________________________ SASID # ______________________________________
Assigned to Room: ____________________________________ Grade: _________________
Departure Date: __________________________________
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