Online Registration Form

Student Record

Student Information

Student First Name *

Middle Name

Last Name *

Home Address

Phone #

Date of Birth

Gender

Place of Birth

Race/Ethnicity

African American/Black American Indian/Alaskan Native Asian Hawaiian Native/Pacific Islander Hispanic White/Caucasian

Date entered the Country

Date entered US School

Has student attended a Paterson Public School?

Transferred from

Plans / Services

IEP 504 Accommodation Plan Bilingual/ESL None of the Above

Family Contacts

Parent / Legal Guardian Information

Mother/Legal Guardian

DOB

Home Address

Resides with child?

Mobile #

Email

Father/Legal Guardian

DOB

Home Address

Resides with child?

Mobile #

Email

Name of Person registering child *

Relationship to child

Primary parent email *

Primary parent phone *

Language preferred for communications

Siblings attending Paterson Public School or Charter

Add one row for each sibling. Leave blank if this does not apply.

Emergency Contacts

Add one row for each emergency contact. Leave blank if this does not apply.

Address Verification

Residence Information

Is your current address temporary?

Due to loss of housing/economic hardship?

Where is the student presently living?

In a hotel/motel With more than one family in a house or apartment In a shelter In a place not designated for ordinary sleeping accommodations

Temporary residence address

Living with

Last rented/leased/owned address

Former district

Registration request

Cause of displacement/homelessness

Authorization

Signature

Parent/Legal Guardian printed name

Date

Electronic signature *

Review the information before submitting it to the PDC100 portal.

Complete the PDC100 registration form online

Registration Form

Student Information

Parent / Legal Guardian Information

Residence Information

Signature