Ashanty Colon Rivera

Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.

Knowledgeable [Desired Position] with solid background in retail operations and customer service, consistently ensuring accurate transactions and positive customer interactions. Proven ability to manage high-volume transactions efficiently and resolve issues promptly. Demonstrated strength in cash handling and communication skills.

• Achieved [Result] through effectively helping with [Task].
• Achieved [Result] by completing [Task] with accuracy and efficiency.
• Achieved [Result] by introducing [Software] for [Type] tasks.
• Reduced complaints [Number]% with new customer service strategies.

• [Area of certification] Training - [Timeframe]

• Student name Date of Birth Grade
• Physician Phone
• Dentist Phone
• Does your child have health insurance? Yes No
• Health insurance company Policy number
• Does your child have dental insurance? Yes No
• Dental Insurance Company Policy number
• If you do not have health insurance, Massachusetts has insurance plans that will provide uninsured children with affordable health care (restrictions may apply). Please contact the school nurse for more information about these programs. All communications will be kept confidential.
• In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated above and to follow his/her instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary. I give my consent for transport to the hospital and treatment of serious illness or injury. I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my child’s health and safety needs. I give permission to exchange information with my child’s primary care physician and/or health care providers for the purpose of referral, diagnosis, and treatment. I recognize that health records, once received by the school district, certain transactions are protected by the HIPAA Privacy Rule, but will become education records protected by the Family Educational Rights and Privacy Act. I also understand that if I refuse to sign such refusal will not interfere with my child’s ability to obtain health care.
• Parent Signature Date
• Please list the Name(s) and Grade(s) and location of sisters/brothers in school.
• Please indicate all that apply to your child.
• Accidents (Explain) Frequent Headaches Treatment
• Allergic Reactions to: History of concussion(s) Yes No
• Describe reaction: Kidney trouble
• Does your child use an Epi-Pen? Yes No
• Asthma Yes No
• Asthma Triggers:
• Does your child need an inhaler or Nebulizer at school? Yes No
• Other respiratory infections/conditions:
• Any disease of bone or joint, arthritis, curvature of spine
• Convulsions/Seizures (Explain) Rheumatic fever
• Diabetes Yes No Ulcers
• Treatment: Medication taken daily - please explain:
• Dental problems Any previous hospitalization, operations, or serious illness?
• Ear infections
• Hearing defects, hearing aids, tubes in ear Physical limitations or restrictions
• Eyeglasses or contact lenses Other – Please explain:

• School District Name and Code: Leominster Public Schools 01530000
• School/District Contact: Laura VanDorn-Director of Special Education and Pupil Personnel Services laura.vandorn@leominsterschools.org 978-534-7700 ext 1307
• Dear Parent/Guardian:
• The purpose of this letter is to ask for your permission (also known as consent) to share information about your child with MassHealth. Local communities in Massachusetts have been approved to receive partial reimbursement from MassHealth for the costs of certain health-related services provided by the district to your child (or children). In order for your community to get back some of the money spent on services, the school district needs to share with MassHealth the following types of information about your child: name; date of birth; gender; type of services provided, when, and by whom; and MassHealth ID.
• With your permission, the school district will be able to seek partial reimbursement for services provided by MassHealth, including, among others, a hearing test or eye exam; a school physical; occupational or speech or physical therapy; some school nurse visits; and counseling services with the school social worker or psychologist. Each year, the district will provide you with notification regarding your permission; you do not need to sign a form every year.
• The school district cannot share with MassHealth information about your child without your permission. As you consider giving permission, please be advised of the following:
• 1. The school district cannot require you to sign up for MassHealth in order for your child to receive the health-related and/or special education services to which your child is entitled.
• 2. The school district cannot require you to pay anything towards the cost of your child’s health-related and/or special education services. This means that the school district cannot require you to pay a co-pay or deductible so that it can charge MassHealth for services provided. The school district can agree to pay the co-pay or deductible if any such cost is expected.
• 3. If you give the school district permission to share information with and request reimbursement from MassHealth:
• A. This will not affect your child’s available lifetime coverage or other MassHealth benefit; nor will it in any way limit your own family’s use of MassHealth benefits outside of school.
• B. Your permission will not affect your child’s special education services or IEP rights in any way, if your child is eligible to receive them.
• C. Your permission will not lead to any changes in your child’s MassHealth rights; and
• D. Your permission will not lead to any risk of losing eligibility for other Medicaid or MassHealth funded programs.
• 4. If you give permission, you have the right to change your mind and withdraw your permission at any time.
• 5. If you withdraw your permission or refuse to allow the school district to share your child’s records and information with MassHealth for the purpose of seeking reimbursement for the cost of services, the school district will continue to be responsible for providing your child with the services, at no cost to you.
• I have read the notice and understand it. Any questions I had were answered. I give permission to the school district to share with MassHealth records and information concerning my child(ren) and their health-related services, as necessary. I understand that this will help our community seek partial reimbursement of MassHealth covered services.
• Parent/Guardian Signature: Date:
• Child’s Name: Date of Birth: SASID # (for district to add):
• Add more children
• Massachusetts DESE Mandated Form 28M/13 Revised June 2018

• Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken at home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.
• Student Information
• Last Name First Name Middle Name Gender F M
• Date of Birth Country of Birth Date left Date arrived in the US
• Child’s language background: (Please list all the languages that your child can speak)
• Native language Other: Other: Other: Other:
• First year in the U.S. school? Yes No
• Is this your child’s first year in the United States? Yes No If no, what was the former school district
• What grade is your child in currently?
• Questions for parents
• 1. What language did your son/daughter learn when he/she first began to talk?
• 2. What language does your son/ daughter speak at home?
• 3. What language does your child use when speaking to other children?
• 4. What language is most spoken by the adults at home?
• Mother’s language background: Native language Speak Read Write
• Other: Speak Read Write
• Father’s language background: Native language Speak Read Write
• Parent requests WRITTEN communication from the school in: English Native language
• Parent requests ORAL communication from the school in: English Native language
• Other Information:
• Signature of Parent/Guardian: Date:

• Most Immediate Prior School Enrollment
• Name of School: Grade:
• Street Name: Phone Number:
• City: State: Zip: Country:
• Contact at School: Fax Number:
• I hearby authorize the release of records for: (Student’s Name)
• Complete Record – Transcripts, Disciplinary Records, All ELL Testing Records and ACCESS Report, Health Records, MCAS, 504 Plan
• Special Education Records - IEP Information
• Please forward all complete records to:
• Please forward all Special Education records to:
• Special Education Records (K-8) Leominster Public Schools Special Education Office 24 Church Street Leominster, MA 01453
• Please send the following information as soon as possible to:
• Bennett School Telephone Number: 978-534-7704 Confidential Fax Number: 978-728-3432
• Email: janice.palmacci@leominsterps.org
• Parent/Guardian Name Phone Number
• Signature Parent/Guardian Date

• Court documentation must be included
• Name
• Signature Date
• Field Trip Form
• I hereby grant permission for my child to participate in any or all school field trips experiences planned by the school and realize I assume all responsibility in doing so.
• Photo Release Form
• I hereby grant permission for my child to participate in any or all opportunities or special events.
• Acceptable Use Policy
• I herby grant permission for my child to have access to the internet provided by the Leominster Public Schools. I have read and understand the Leominster Public Schools Acceptable Use Policy. I understand that the rights are conditional. He/she must adhere to the responsibilities described in the policy. Failure to do so may results in loss of internet or network privileges.
• Parent/Guardian, Caregiver Signature: Date
• I understand that pursuant to Massachusetts law and Leominster School Committee policy, students who actually reside in the City of Leominster may attend the Leominster Public Schools and students who do not actually reside in the City of Leominster may not attend the Leominster Public Schools, unless a policy exception applies. I hereby acknowledge that no such policy exception applies to the child named on this registration form. I also acknowledge that I am required to notify the school Principal, in writing, of any changes in said student’s address within five (5) calendar days of such change of address.
• I understand that this certification will be relied upon by the Leominster Public Schools for the purpose of determining the eligibility to attend the Leominster Public Schools on the basis of residency. If it is subsequently determined that the student does not actually reside in Leominster, I understand that the student’s enrollment in the Leominster Public Schools will be promptly terminated and that I will be liable to the Leominster Public schools for the student’s tuition for the duration of the student’s attendance in the Leominster Public Schools.
• I hereby certify that I can and will, upon request, substantiate all statements make on the application and that such statements are true, accurate, and complete and are made in good faith.

• Please provide 2 emergency contacts in case parents/guardians/caregivers are unavailable.
• Name Phone # Relationship to Student
• Sibling Information – Please list all siblings
• Name Date of Birth Name of School Current Grade
• Military Status: In the past year, did one or both of the student’s parents or guardians:
• Serve as an active duty member of uniformed services? Yes No
• Become medically discharged or retired from uniformed services? Yes No
• Die while on active duty? Yes No
• Note: Military families may be provided special considerations for registration requirements such as guardianship papers. Family military status does not influence school assignment.
• School History – Where has your child attended school in the past?
• Name of School City and State Grades Attended
• Special Education / Students with Disabilities:
• Does your child currently have an IEP or receive special education services? Yes No
• Does your child currently have a 504 Plan or received disability accommodations? Yes No
• A signed copy of your child’s IEP/504 MUST be submitted at the time of enrollment in order to be considered complete.

• Are you questioning whether you have the necessary documents for enrollment? Please talk with us.
• Has the child ever registered with Leominster Public Schools in the past? Yes No If YES, what year(s)?
• Last: First: Middle:
• Grade Entering: Gender: Male Female Non-Binary
• Home Address, Apt. # City, State, Zip Code
• Phone #: Date of Birth (MM/DD/YYY)
• Birth City: Birth Country:
• If Birth Country is not the United States Has the child completed 3 years of schooling in the US? Yes No
• Race/Ethnicity
• Please note that the Leominster Public Schools is committed to ensuring that the school is free from discrimination in education. The following 2 questions are taken from the state reporting categories. We appreciate your cooperation.
• 1. Race: American Indian/ Alaskan Native Asian Black/ African-American Hawaiian/ Other Pacific Islander White/ Caucasian
• 2. Ethnicity: Hispanic/ Latino Not Hispanic/ Latino
• Parent/Guardian/Caregiver 1
• Name:
• Relationship to Student:
• Person lives with student: Yes No
• Portal Access: Yes No
• Address, Apt. #:
• City/State/Zip:
• Home Phone:
• Cell Phone:
• Work Phone:
• Email Address:
• Parent/Guardian/Caregiver 2

• Required Forms – Completed and Signed:
• 1. Enrollment Packet
• 2. Release of Records
• 3. Home Language Survey
• 4. Health Information Form
• 5. Medicaid Form
• Required Documents:
• 6. Proof of Age – Municipal birth certificate. A passport will be accepted only if born outside of the country
• 7. Proof of Address – Provide ONE of the following: Lease
• Section 8 Agreement
• Purchase & Sales Agreement
• Mortgage Statement
• Deed
• Property Tax Bill
• 8. Proof of Occupancy – Provide ONE document dated within 30 days. Electric Bill
• Gas Bill
• Oil Bill
• Cable Bill
• Cell Phone Bill
• Water Bill
• 9. Proof of Parent/Guardian/Caregiver Identity – Provide ONE of the following: Valid Driver’s License
• State Photo ID
• Passport
• Military ID
• Other government issued photo ID
• 10. Student Immunization Record Including Lead Test – Must be submitted at the time of registration
• 11. Physical Exam Record – Current physical, must be submitted at the time of registration
• 12. Transcripts – For grades 6 -12
• Additional Documents – If Applicable:
• Copy of student’s IEP or 504 Plan
• Guardianship Papers or Notarized Caregivers Authorization Affidavit: Provide if the person registering the student is other than the parent listed on the student’s birth certificate.
• Residency Affidavit – Request the form at the Parent Information Center if the student and family are living with relatives/friends and are not named on the Proof of Address document or Proof of Occupancy documents. Proof of Address & Occupancy for the person with whom you are staying are also required.