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Book Policy Manual
Section 5000 - Students
Title Residency Affidavit Form
Code 5111-R Form 5
Status Active
Last Revised April 11, 2022
5111(f)
Colchester Public Schools
Residency Affidavit
CONFIDENTIAL
The Colchester Public Schools, in compliance with statute 10-253(d) of the State of Connecticut, requires this form to be
completed for any student who claims residence in Colchester and is not residing with a parent(s)/guardian(s) and whose
parents/guardians are not residing in Colchester. This form is required when there is a question about the child’s actual
residence. The student, parent/guardian and person with whom the student is living must fill out this form together. A
completed Host’s Statement and Parent/Guardian Statement shall accompany this form.
Date ____________________
1. Student’s Name _____________________________________________ DOB: ____________________
(Last) (First) (Middle)
2. Student’s Colchester Address _______________________________________________________________________
(No. and Street)
3. Name of Person With Whom Student Lives ____________________________________________________________
Relationship _______________________________________ Email Address:_________________________________
Address ________________________________________________________________________________________
(No. and Street)
Telephone #_____________________________
4. Date Student Moved to Colchester ___________________________________________________________________
(Month/Day/Year)
5. Student’s Former Address _________________________________________________________________________
(No. and Street) (Town) (State)
6. Former School _________________________________________________________ Grade ____________
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7. Name of Student’s Parent/Guardian _________________________________________________________________
Address ________________________________________________________________________________________
(No. and Street) (Town) (State)
Parent/Guardian Email: ______________________________ Telephone # _____________________________
8. Name of Student’s Parent/Guardian__________________________________________________________________
Address ________________________________________________________________________________________
(No. and Street) (Town) (State)
Parent/Guardian Email: ______________________________ Telephone #_____________________________
9. Name, Address, Telephone Number, and Email Address of Student’s Court Appointed Legal Guardian, if applicable:
_______________________________________________________________________________________________
_________________________________________________________________
Signature of Person with Whom Student Lives Date
_________________________________________________________________
Signature of Parent/Guardian Date
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