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: __________________________________