Student Registration And Directory Release Form Page 2
ADVERTISEMENT
1
2EMERGENCY C ONTACTS
Name________________________________ H ome P hone _ __________________ W ork P hone _ __________________
Name________________________________ H ome P hone _ __________________ W ork P hone _ __________________
Name________________________________ H ome P hone _ __________________ W ork P hone _ __________________
Student’s D octor/Clinic _ ___________________________ P hone N umber _ _______________ H ospital o f C hoice _ _________________________
Does t he s tudent h ave a ny s pecial m edical c onditions/allergies/procedures o f w hich w e s hould b e a ware? P lease l ist:
__________________________________________________________________________________________________
ELECTRONIC C OMMUNICATION S YSTEM: I h ereby u nderstand t hat s tudents o f _ ____________________________________ w ill be
granted a ccess t o t he s ystem’s e lectronic c ommunications s ystem w hich i ncludes a ccess t o t he I nternet a nd W orldwide W eb. T his
access i s a p rivilege, n ot a r ight. T hey s ystem m ay s uspend o r r evoke a s ystem u ser’s a ccess u pon v iolation o f s ystem p olicy a nd/or
administrative r egulations r egarding a cceptable u se o r u pon w ritten p arental r equest t o t he c ampus p rincipal.
I f urther u nderstand t hat t he S chool w ill n ot p ublish m y c hild’s i ndividual p hotograph, v ideo, a nd/or l ast n ame w ithout m y w ritten
permission.
STUDENT’S N AME _ ________________________________________________________________
PARENT/GUARDIAN S IGNATURE _ _________________________________________________ D ATE _ ________________
PARENT E a MAIL A DDRESS ( OPTIONAL): _ _____________________________________
would l ike t o c ommunicate w ith y ou
via e -‐mail s hould y ou w ish. P rovision o f a n e -‐mail a ddress i s n ot r equired. I f y ou d o n ot p rovide a n a ddress, t he s ystem w ill c ontinue
to c ommunicate w ith y ou i n i ts r egular m anner t o a ssure c ontinued p rovision o f v ital a nd i mportant i nformation.
My e -‐mail a ddress i s _ _________________________________________________________________
STUDENT’S N AME _ ________________________________________________________________
PARENT/GUARDIAN S IGNATURE _ _________________________________________________ D ATE _ ________________
DIRECTORY I NFORMATION: _ ___________________________________ r egularly r eceives r equests f or d irectory information
on s tudents e nrolled i n t he S ystem. D irectory i nformation i ncludes, b ut i s n ot l imited t o, i nformation s uch a s s tudent n ame,
address, t elephone n umber, d ate a nd p lace o f b irth, p hotographs, p articipation i n s ports, g rade l evel, d ates o f a ttendance,
enrollment s tatus a nd e : mail a ddress.
______ I G IVE _ _____ I D O N OT G IVE p ermission t o r elease s tudent d irectory i nformation.
STUDENT’S N AME _ ________________________________________________________________
PARENT/GUARDIAN S IGNATURE _ _________________________________________________ D ATE _ ________________
All o f t he i nformation g iven o n t his f orm i s c orrect.
PARENT/GUARDIAN S IGNATURE _ _________________________________________________ D ATE _ ________________
Charter School Tools
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life