Affidavit by person in custodial RELATIONSHIP SEEKING to enroll a child

 

Instructions

Please complete this form, sign it, have your signature notarized, and return it to the District’s Central Administration Office. Proof of your own residency in the Brentwood Union Free School District must be submitted with this affidavit. 

This is a legal document. Any person giving false information may be subject to prosecution for the crimes of perjury and/or offering a false instrument. In addition, if you enroll a child knowing that s/he does not meet the legal standards for enrollment, you may be liable for the payment of tuition costs for the student. The information provided by you will be used by Brentwood Union Free School District to determine whether a child is entitled to a free public education in the District’s Schools.

If you have a court order granting you custody or legal guardianship, you do not need to complete this form. Instead, bring a copy of the court order to the District’s Central Administration Office.

Please answer all questions.

In the matter of the ResidencY of: _____________________________________

Student name

STATE OF NEW YORK )

}: ss.:

COUNTY OF SUFFOLK )

The undersigned individual(s), being duly sworn, depose(s) and say(s), under penalties of perjury, as follows:

1. My name is (our names are): .
2. I (we) are requesting that the following student be admitted to the public schools of Brentwood Union Free School District (insert name of student here): .
3. I (we) live at the following address: .
4. My (our) home telephone number is: .
5. My (our) occupation(s) is (are): .
6. The student whom I (we) seek to enroll lives with me (us) during the following days each week and months each year: .
7. If the student lives someplace else during some of the days or the week or some of the months of the year, please explain (if not applicable, fill in “N/A”): .
8. The student’s date of birth is: .
9. The grade in which I (we) seek to enroll the student is .
10. The name of the student’s natural parent(s) is (are) .
11. The address(es) of the student’s natural parent(s) is (are) .
12. The reason why the student does not live with his/her natural parent(s) is .
13. The reason why the student lives with me (us) is: .
14. The student has lived with me (us) continuously since .
15. The student will continue to live with me (us) until .
16. I am (we are) authorized to make decisions about the following (check all that are applicable):

• The student’s medical treatment
• The student’s psychological/psychiatric treatment/counseling
• The student’s class placement and program
• The student’s special education placement, if applicable
• The student’s class trips and activities
• None of the above.

17. The student’s natural parent(s) continue(s) to be authorized to make decisions about the following (check all that are applicable):

• The student’s medical treatment
• The student’s psychological/psychiatric treatment/counseling
• The student’s class placement and program
• The student’s special education placement, if applicable
• The student’s class trips and activities
• None of the above.

18. I (we) expect to consult with the student’s natural parent(s) about the following decisions: . Final authority for these decisions will be with .
19. I (we) are responsible for paying the following expenses:

• The cost of providing housing for the student
• The cost of providing food for the student
• The cost of medical care/health insurance for the student
• The cost of providing clothes for the student
• The cost of providing school supplies for the student
• The cost of providing recreational opportunities and equipment (or toys) for the student
• Other expenses:

20. The student’s natural parent(s) continue(s) to be responsible for paying the following expenses:

• The cost of providing housing for the student
• The cost of providing food for the student
• The cost of medical care/health insurance for the student
• The cost of providing clothes for the student
• The cost of providing school supplies for the student
• The cost of providing recreational opportunities and equipment (or toys) for the student
• Other expenses

21. I (we) expect to receive reimbursement from the student’s natural parent(s) for the following expenses: .
22. The student will spend time with his/her natural parent(s) as follows: .
23. I (we) understand that the Brentwood Union Free School District will rely upon the truthfulness of the statements made in this document in deciding whether or not to enroll the student in the public schools of the School District.
24. I (we) understand that perjury is a Class A misdemeanor pursuant to section 210.45 of the penal code. Any person or persons, in addition to the parents or guardians, who provide false evidence of residency, may be prosecuted.
25. I (we) further understand that the Brenwtood Union Free School District does not have authority to confer legal custody or guardianship status on me (us) with respect to the student, and that I (we) should secure legal counsel of my (our) own if I (we) wish to obtain such legal custody or guardianship status.

____________________________________

Signature

_________________________________

Printed name

Sworn to before me this ____

day of ____________, 20___

 

Notary Public

____________________________________

Signature

_________________________________

Printed name

Sworn to before me this ____

day of ____________, 20___

 

Notary Public

ACKNOWLEDGMENT OF CUSTODIAL RELATIONSHIP

To Be Completed By The Student’s Natural Parent(s):

I (we), _________________________,acknowledge that the statements made in the Affidavit By Person In Custodial Relationship Seeking To Enroll A Child, completed and signed by ________________________[Insert the full name(s) of Custodian(s)], are accurate and true.

I (we), ______________________, have authorized ___________________[Insert the full name(s) of Custodian(s)] to have custody of ______________________[Insert Name of Student] under the terms described in the Affidavit By Person In Custodial Relationship Seeking To Enroll A Child.

____________________________________

Signature

_________________________________

Printed name

____________________________________

Signature

_________________________________

 

Printed name

Approved by the Board of Education: 01/21/10

Revision approved by the Board of Education: 08/17/17

Revision approved by the Board of Education: 12/17/20

Revision approved by the Board of Education: 09/26/24

Download the School Admissions Exhibit Custodial Affidavit PDF