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ADDRESS VERIFICATION POLICY
Parent(s) or legal guardian(s) of students who were not enrolled in the
Pawtucket public school district for the preceding school year are required
to submit three written evidence of residency prior to enrollment. Evidence
consists of the parent’s or legal guardian’s payroll stub, bank statement,
health insurance statement, auto insurance statement, federal/state/ local
correspondence, or utility bill such as gas, electric, cable, or telephone
(not cellular).
The parent(s) or guardians are further required to execute a sworn affidavit
attesting that they are legal parent(s) or guardian(s) and that the student
resides with them. The affidavit also certifies that the parent(s) or
guardian(s) agree to notify the Superintendent of Schools within the (10)
days of the change in the residence of the student.
The parent(s) or guardian(s) of all other students are also required to
complete an affidavit and show proof prior to the end of the second week of
the school year or the student may be dropped from enrollment.

AFFIDAVIT OF RESIDENCY
I hereby certify that I am the parent/legal guardian of ___________________________ who resides with me at _____________________________________Pawtucket, Rhode Island. Furthermore, I hereby agree that I am responsible for notifying the Superintendent of Schools of the Pawtucket School Department should I, or my child/ward change our residence to an address outside of the city of Pawtucket. I also realize that in order to attend the Pawtucket school district it is necessary that my child/ward be a resident of the city of Pawtucket. Accordingly, I hereby agree to be responsible for reasonable tuition for my child/ward should his/her residence change to outside the city of Pawtucket. This responsibility runs from the date of child/ward change of address until the date upon which the Superintendent of Schools is notified of such change of address. (Affidavit of Residency) (Signed under the pains and penalty of perjury) PLEASE SIGN THIS FORM & ATTACH PROOF OF RESIDENCY RETURN BOTH TO THE SCHOOL
EMERGENCY DISMISSAL FORM
(For parents/guardians of elementary children ONLY)

In the event of emergency school closing, ALL parents/guardians should
plan to have someone at home to receive and supervise their children
should such an emergency arise. In order to meet this responsibility,
the school is asking all parents or legal guardians to inform the
school of their arrangements to meet this type of emergency. Please
complete this form, and return it to your child’s teacher immediately.
CHECK ONE:
___ A parent/legal guardian, designated adult, or an older child will Child has been instructed to go to the home of: Name____________________________________________________ Address___________________________________________________ Telephone No._____________________________________________ Date

Principals/teachers are not able to call individual parents/guardians.
OVER THE COUNTER MEDICATION POLICY FORM

TO ALL PARENTS OR GUARDIANS:
Please complete the Over-The-Counter Medication Policy Form below and have your child return it to
his/her classroom/homeroom teacher as soon as possible.
IT IS IMPERATIVE THAT WE RECEIVE A FORM FROM EACH CHILD REGISTERED IN
OUR SCHOOLS.

___ Yes, I give the school nurse permission to administer the following over-the-counter medications as
needed: Ibuprofen, Tylenol, Benadryl, and an antacid, as well as throat lozenges.
___ No, I do not wish the nurse to administer any over-the-counter medications to my child.
Please answer the following questions regarding your child:
Child’s Name:
Other information regarding your child you would like the School Nurse Teacher to know:

Source: http://www.psdri.net/Portals/Pawtucket/District/docs/Parents%20and%20Students/Registration_Forms_-_Supplimentary_Package.pdf