PLEASE ANSWER THE FOLLOWING QUESTIONS Sample Clauses

PLEASE ANSWER THE FOLLOWING QUESTIONS. Does your child take any Foreign language courses in Grades 6, 7 or 8? If yes, please check off one or more of the following two language selections. Does your child take band or chorus in Grades 6-8? Yes French Yes No Spanish No If yes, please check off one or both of the following two course selection. Does your child participate in athletics? (for Grades 6-12) Band Yes Chorus No NEWARK CENTRAL SCHOOL DISTRICT ATHLETIC DEPARTMENT FORM FOR GRADES 7-12 Previous School Attended: Student’s address while attending the above school Street and Number City, State, Zip With whom did student reside at this address? Father Mother Guardian ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ NEWARK, NEW YORK 14513 (▇▇▇) ▇▇▇-▇▇▇▇ FAX (▇▇▇) ▇▇▇-▇▇▇▇ Superintendent of Schools Assistant Superintendent Curriculum & Instruction Director of Pupil Services SIGNATURE OF PARENT/GUARDIAN: ** These records should include ** *Please provide numerical equivalent if alphabetical grades are reported* Newark Middle School – Grades 6 – 8 Attn: ▇▇▇▇▇ ▇▇▇▇, Building Secretary ▇▇▇▇▇▇▇ School – Grades K-2 Attn: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, Building Secretary Lincoln School – Grades K-2 Attn: ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, Building Secretary FOR OFFICE USE ONLY Student #: Grade: EC: Teacher: LAST NAME RELATIONSHIP TO STUDENT STUDENT INFORMATION **(PLEASE PRINT, EXCEPT WHERE SIGNATURE IS REQUIRED)** SIBLINGS / RELATIONSHIPS IN THE HOME LAST NAME FIRST NAME M.I GENDER M.I FIRST NAME GRADE AGE, WRITE “N/A” AT F CHILD IS NOT SCHOOL Student’s Name Newark Central School District Registration Form, Page 2 Newark Central School district assumes that all custodial parents and legal guardians listed below are allowed to pick this student up from school unless parent provides school with a current, legal, valid court order indicating otherwise. Signature PARENT/GUARDIAN INFORMATION Student’s Name Newark Central School District Registration Form, Page 3 EMERGENCY CONTACTS (Beyond Parent/Guardian) DAYCARE PROVIDER In the case of when parents are living in separate households, both parents may want to be included in any mailings the school may send with information in regards to their child. Please indicate in the spaces below those parents who are to be included in mailings. If there are any legal restrictions (Ex.: Order of Protection, Sole Physical Custody with supervised visitation) please indicate in the Custodial Information section of this registration on Page 1.

PLEASE ANSWER THE FOLLOWING QUESTIONS. Have you ever engaged in sexual misconduct, such as sexual abuse, in any confinement setting such as jails, prisons, and/or juvenile detention facilities? YES ❑ NO ❑X

PLEASE ANSWER THE FOLLOWING QUESTIONS. Your answers will be held in the strictest of confidence. (Circle one) Yes No 1. Do you currently use illegal drugs? Yes No 2. Have you ever been convicted of the illegal manufacture, sale or Possesion of drugs? Yes No 3. Have you ever been convicted of a criminal offense? (Conviction of a crime is not an automatic bar to employment. Lords of Soccer will consider the nature of the offense, the date, and the relationship between the offense and the position applied for.) Yes No 4. Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? Yes No 5. Are you subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection? I understand that the Lords of Soccer camps may deny employment to any person who answers any of the above questions, numbered 1-5,

PLEASE ANSWER THE FOLLOWING QUESTIONS. Does your child take any Foreign language courses in Grades 6, 7 or 8? If yes, please check off one or more of the following two language selections. Does your child take band or chorus in Grades 6-8? Yes French Yes No Spanish No If yes, please check off one or both of the following two course selection. Does your child participate in athletics? (for Grades 6-12) Band Yes Chorus No NEWARK CENTRAL SCHOOL DISTRICT ATHLETIC DEPARTMENT FORM FOR GRADES 7-12 Previous School Attended: Student’s address while attending the above school Street and Number City, State, Zip With whom did student reside at this address? Father Mother Guardian Superintendent of Schools (▇▇▇) ▇▇▇-▇▇▇▇ FAX (▇▇▇) ▇▇▇-▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ** These records should include ** *Please provide numerical equivalent if alphabetical grades are reported*

PLEASE ANSWER THE FOLLOWING QUESTIONS. Skipper: Address:

PLEASE ANSWER THE FOLLOWING QUESTIONS. If yes to any of the following questions, please attach a detailed information sheet If yes to any of the following questions, please attach a detailed information sheet. Please include name of court in which suit was filed, caption and docket number of case, name and address of attorney defending you, and any other relevant details. If yes to any of the following questions, please include a sheet of detailed information. CLINICAL PRIVILEGES PROFICIENT REQUESTED GENERAL ANESTHESIA: REGIONAL ANESTHESIA: DIAGNOSTIC/THERAPEUTIC BLOCKS: PROCEDURES: IV ADMINISTRATION OF:

PLEASE ANSWER THE FOLLOWING QUESTIONS. How many people live in the home? _____________________________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS. Are you under indictment or information (an information is a formal accusation of a crime made by a prosecuting attorney) in any court for a crime for which a judge could imprison you for more than one (1) year? YES □ NO □

PLEASE ANSWER THE FOLLOWING QUESTIONS. Have you ever been asked to give a right-of-way easement to EJ Water?