WAYNE CENTRAL SCHOOL DISTRICT ● Ontario Center, New York 14520

RESiDENCY AFFIDAVIT OF PARENT(S)
 
STATE NEW YORK  (
COUNTY OF WAYNE ( ss.:
TOWN OF …………….(
 
I (we), the undersigned, being duly sworn, depose and say that: I (we) am (are) the parent (s) of the student named below and certify that the information provided herein is true and complete to the best of my (our) knowledge:
 
1) Student’s Name: ……………………………………………..Grade (20…-…)……………………….
 
2) Student’s Date & Place of Birth: …………………………………………….Age…………………..
 
 ]3) Student’s Present Full-Time Address:
 
 ……………………………………………………………………………………………………………….
 
4) Name & Address of Student’s Father:
 
……………………………………………………………………………………………………………….
 
5) Name & Address of Student’s Mother:
 
……………………………………………………………………………………………………………….
 
 6) Name(s) & addresses of other children in student’s family:
 NAME(s)  ADDRESS
……………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
 
7) What school has this student most recently attended?
 NAME(s)  ADDRESS
……………………………………………………………………………………………………………….
 
8)  Where did this student resident during the previous school year?
Mailing Address: …………………………………………………………………………………………
9) Are you responsible for the financial support of this student?  Yes   No
  If NOT, what percentage do you provide ?      ……………..%
10)  In case of medical or other emergency, who will be responsible for decisions affecting this student?
 NAME(s)  ADDRESS
……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
PHONE: (Home)……………………………………..(Work) ……………………………………………

(continued....)

Exhibit 5151-E-3
Page 1 of 2
 
11)  lf this student will reside in the Wayne Central School District, but not with his or her parent(s) or guardian(s), please indicate with whom he or she will reside?
 NAME(s)  ADDRESS
……………………………………………………………………………………………………
 
 PHONE: (Home) ………………………..(Work)…………………………………….
 
12)  Date whenthis student ceased or will cease to reside with his or her parent(s) or guardian(s) or will begin residence with the person(s) noted in Item 11, above: …………
 
13) How long will this student reside with the person(s) noted in item 11, above? ……….
 
14)  Will this student reside in the home of his or her parent(s) or guardian(s) at any time during the following periods:
 During the Week  On Weekends  During School Recess Periods
  IF YES, when & why? ……………………………………………………………..
 
15)   Please indicate as fully as possible the reasons why this student will no longer reside with his or her parents:
 
 
 

PARENT(s) CERTlFlCATlON
 

I (we) hereby certify that: I (we) have relinquished all custody and control over the student named in Item 1, above, to the person(s) named in Item 11, above, including the right to make decisions pertaining to the health, welfare and education of the student If the student is permitted to attend Wayne Central School District, I (we) agree to promptly notify the Superintendent of Schools in the event that there is any change in the information provided
herein.
Signature …………………………………………………………..Date………………………..
Signature …………………………………………………………..Date………………………..
Subscribed and sworn before me on this day of ……………………………..., 20 ………
 
       Notary Public…………………………………………