Enrollment Forms Packet (EFP)

Required For? Item Description Provided by?

Required for all Students

Proof of Age Copy Official Birth Certificate (not the hospital issued certificate) Provided by you

Proof of Residency Copy of rental/mortgage document OR Military Order OR Current utility bill OR Notice of base housing assignment or Notarized statement of residence if living with relative. Provided by you

Report Card The most recent Report Card, except for students enrolling in Kindergarten or always homeschooled. Provided by you

Immunization Record and Results of a Tuberculosis exami-nation

Current Immunization Record. Tuberculosis (TB) clearance must be completed within one year before first entrance into school in Hawaii and must be performed by the State of Hawaii Department of Health or by a U.S. licensed physician, advanced practice registered nurse (APRN), or physician assistant (PA). Please fill out and return the Request for Immuni-zation Exemption on Religious Grounds form (included in the Enrollment Forms Packet) if applicable.

Provided by you

Student’s Health Record

A physical examination must be completed within one year before first attending school in Hawaii and must be performed by a U.S. licensed physician, APRN, or PA.

Provided in this packet

Release of Records

“This form is required to transfer your student’s previous school records. If your student is entering Kindergarten or was not previously enrolled in a school, write “Not Applicable” on the form. THIS IS NOT A WITHDRAWAL FORM. Contact your student’s school to follow proper withdrawal procedures.”

Provided in this packet

eHTA ApplicationPlease complete this form and submit. (This is a virtual option for grades K-8. Applicant must be a sibling of a currently enrolled student, or transferring from another virutal school.

Provided in this packet

Network and Internet User Agreement

This form requires the signature of all students and that of the Legal Guardian for students under the age of 18.

Provided in this packet

Home Language Survey Please make sure that you answer all sections of this form. Provided in this

packet

Self Administration of Medication

Please have your physician complete and sign (if applicable). If not applicable, please write “N/A” and sign form.

Provided in this packet

McKinney-Vento Eligi-bility Questionnaire Please make sure that you answer all sections of this form. Provided in this

packet

Emergency Card Please complete this form and submit. Provided in this packet

Student Publication/Video Release Please complete this form and submit. Provided in this

packet

Hawaii Homeschool Students

Form 4140 from District School This form is located at the school district office. Provided by you

Required for all 9R -12th Grade Students

Most Recent Tran-script

You will need to request an unofficial transcript from your student’s current school, which will show your student’s academic standing. This is required in order to place all 9R, 10, 11 and 12th graders enrolling in second semester. Once your student is approved, we will receive the official transcript.

Provided by you

Required for student with an IEP or other Special Education needs

IEP A copy of your student’s current IEP (Individualized Education Plan). Because the IEP expires yearly, please submit the current IEP. Provided by you

Evaluation Report The Evaluation Report is valid for 3 years. If you do not have a copy of your student’s ER, you can request a copy from your student’s current school. Provided by you

Required for students that have a 504 plan

504 Accommodation Plan

A copy of your student’s current 504 Accommodation Plan. Because the 504 expires yearly, please submit the current 504. Provided by you

Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documenta-tion in order to complete this step in the enrollment process. You can fax or mail the required paperwork .

Important Note: Please send copies, do not mail the original documents

Fax (preferred): Scan and Email: Mail: 1-855-265-3942 htafax@k12.com Hawaii Technology Academy Enrollment Processing Center 2300 Corporate Park Drive Suite 200 Herndon, VA 20171

Hawaii Technology AcademyEnrollment Processing Center2300 Corporate Park Drive, Ste 200Herndon, VA 20171

Ph. 1.855.503.7136Fx. 1.855.265.3942www.k12.com/hta

General Information

e-HTA ADMISSION APPLICATION FORM

This K- grade 8 pilot program will have limited enrollment and be available for current HTA students and siblings or transfer students from another accredited virtual learning program. Families applying to the e-HTA pilot program must be approved by administration. **Please note that familes enrolled in e-HTA commit to the program for the entire 2013-2014 school year and may not transfer into HTA’s blended learning program on Oahu.

Applicant Information

First Name Middle Name Family Name Preferred Name or Nickname

Home Address City State/Province Countr y Zip/Postal Code

❐ Male

❐ Female Age Date of Bir th (Mo/Day/Year) Countr y of Bir th

E-Mail Address

Home Telephone (include countr y, city, and area codes)

Month / Year of Proposed Entr ance Current grade Applying for Grade

Family Information

Parent/Guardian

Name Occupation Name of Company

Home Address City State/Province Countr y Zip/Postal Code

Home Telephone (include countr y, city, and area codes)

Fax Number (include countr y, city, and area codes)

Parent/Guardian

E-Mail Address

Name Occupation Name of Company

Home Address City State/Province Countr y Zip/Postal Code

Home Telephone (include countr y, city, and area codes) Business Telephone (include countr y, city, and area codes)

E-Mail Address

_________________________________________ __________________________

Signature of Parent or Guardian Date

Mumps

Rubella

Student Address Label

Medical StatuS

Department of Education

Student’S HealtH RecoRd

Name

Birthdate

Parent’s Name

PHySician’S exaMination code: n-noRMal; a-abnoRMal; c-coRRected; R-Receiving caRe

(Last) (First) (Middle Initial)

(Mother/Guardian) (Father/Guardian)

Month Day Year

Please complete the following sections (CHECK IF YES)

Date

/ /

/ /

/ /

Wei

ght

Gra

de

Hei

ght

/ /

Ext

rem

ities

Sco

liosi

s

Blo

od

Pre

ssur

e

Ski

n

Abd

omen

Lung

s

Hea

rt

Tee

th

Thr

oat

Nos

e

Eye

sHearingVision

Ner

vous

S

yste

m

R. L. R. L. Ear

s

Nut

ritio

n

Significant Findings and Recommendations R

evie

wed

Im

mun

izat

ion

Rec

ord

(Che

ck if

Yes

)

Varicella Immunity

Secondary to Disease (DATE)

Provider’s Stamp or Printed NameProvider’s Signature

Com

plet

ed

PP

D S

cree

ning

(C

heck

if Y

es)

See

Res

ults

Bel

ow

/ /

/ /

/ /

/ /

iMMunizationS (vaccineS, dateS given: MontH/day/yeaR)

Physician, APRN, PA or Clinic (Signature or stamp if different from above)

dental exaMination

Date Read

Results (mm)

Physician, APRN, PA, or Clinic (Signature or Stamp if Different

from Above)

Date Given

LocationDate Results

tubeRculoSiS exaMination Mantoux teSt (intRadeRMal)

cHeSt x-Ray

/ /

/ /

/ /

/ /

/ /

/ /

/ /Dental Check-Up

*OFFICE USE ONLY (Rev. 2006)

Preschool: Entry Date

Elementary: Entry Date

Intermediate/Middle: Entry Date

High: Entry Date

❑

❑

Female

Male

/ // // // /

Allergy (type) Cancer/Leukemia Hearing Problems Rheumatic HeartAsthma Chronic Cough/Wheezing Heart Disease Sickle Cell AnemiaVision Problems Diabetes Hemophilia Seizures

❑❑❑

❑❑❑

❑❑❑

❑❑❑

DTaP, DTP, DT, or Td

Type Date Given

Polio (IPV or OPV)

Type Date Given

Date Given

MMRHIB Haemophilus influenzae type B

Date Given

/ /

/ /

OTHER

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Date Given

Date Given

/ /

/ /

/ /

/ /

Date Given

Pneumoccal (Prevnar)Hepatitis B

Date Given

/ /

/ /

/ /

/ /

Type

Measles

Type Date Given

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /Varicella

/ // /

/ /

/ /

/ /

Hep A*

* in future, will be required

Health History Comments: Include Referrals and Reports. Recommendation for significant findings. (Please Print)

STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, Rev. 12/05, RS 06-0698 (Rev. of RS 02-0693)

Signature & TitleDateDate Signature & Title

Hawaii Technology Academy94-810 Moloalo Street 2nd Floor Waipahu, HI 96797

Ph. 1.808.671.3178Fx. 1.808.680-7498www.k12.com/hta

Student Information

Student’s Full Name: first middle last

Student’s Date of Birth:

Student’s Legal Address: street apt #

city county state zip

Home Phone:

Check below if applicable: o Student was always previously homeschooled

o Student is enrolling in Kindergarten

Name of Prior School:

School’s Address: street

city county state zip

School’s Phone: School’s Fax:

Name of Parent or Legal Guardian: first last

Parent/Guardian’s Signature: Date:

Release of Student RecordsPlease accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and immunization records).

Homeschooled or Never Previously Enrolled in School (Fill out only if applicable)

Prior School Information

Sign and Date below

SCHOOL OFFICIALS ONLY:

Send student records to: Hawaii Technology Academy 94-810 Moloalo Street 2nd Floor Waipahu, HI 96797

Student’s Name: Student’s Home Phone:

4

Hawaii Technology Academy94-810 Moloalo Street 2nd Floor Waipahu, HI 96797

Ph. 1.808.671.3178Fx. 1.808.676.5470www.k12.com/hta

Hawaii Technology Academy Network and Internet User Agreement

Welcome to the Hawaii Technology Academy Network and the Internet

CONDITIONS, RULES, AND ACCEPTABLE USE AGREEMENTThe Hawaii Technology Academy (HTA) has actively pursued making advanced technology and increased access to information available to our students and staff. We are pleased to offer Internet and networking services. We believe this computer technology will help propel our schools into the information age by allowing students and staff to access and use a variety of information sources, communicate and share information with individuals or groups of other students and staff, and significantly expand their knowledge base. The Internet is a tool for lifelong learning and only begins to open the door to expand your student’s education experience.

PROPER AND ETHICAL USE:With this new learning tool students and staff must understand and practice proper and ethical use.

HTA recognizes that technology provides ways to access the most current and extensive sources of information. Technology also enables students to practice skills and to develop reasoning and problem-solving abilities.

ONLINE SERVICES/INTERNET ACCESS:HTA intends that the Internet and other online resources provided are to be used to support the instructional program and further student learning.

As the Internet contains an unregulated collection of resources, HTA cannot guarantee the accuracy of the information or the appropriateness of any material that a student may encounter. Therefore, before using the online resources, each student and his/her parent shall sign and return the Acceptable Use Agreement. This agreement shall specify user obligations and responsibilities and shall indemnify HTA for any damages. The student and parent shall agree to not hold HTA responsible for materials acquired by the student on the system, for violations of copyright restrictions, user mistakes or negligence, or any costs incurred by users.

Parents shall supervise students while using online services.

CONDITIONS AND RULES FOR USE:1. Acceptable Use

a) The purpose of the Internet is to facilitate communications in support of research and education, by providing access to unique resources and an opportunity for collaborative work. To remain eligible as a user, the use of your account must be in support of and consistent with the educational objectives of HTA. b) Transmission of any material in violation of any state regulation is prohibited. This includes, but is not limited to, copyrighted material, threatening or obscene material, or material protected by trade secret. c) Use for commercial activities is generally not acceptable. Use for product advertisement or political lobbying is also prohibited.

2. PrivilegeThe use of the Internet is a privilege, not a right. Inappropriate use, including any violation of these conditions and rules, may result in cancellation of the privilege.

3. MonitoringHTA reserves the right to review any material on HTA-issued accounts and to monitor HTA files and Internet server space in order to make determinations on whether specific uses of the network is appropriate. In reviewing and monitoring user accounts and Internet server space, HTA shall respect the privacy of user-accounts.

4. Network EtiquetteAll users are expected to abide by the generally accepted rules of network etiquette. These include, but are not limited to, the following:a) Be polite. Do not get abusive in your messages to others. b) Use appropriate language. Do not swear, use vulgarities, or any other offensive language. Do not engage in activities that are prohibited by state or federal law. c) Do not reveal your personal address or phone number or similar information to others. d) Note that electronic mail (e-mail) is not guaranteed to be private. Messages relating to or in support of illegal activities will be reported to the authorities and may result in loss of user privileges. e) Do not use the network in such a way that you would disrupt the use of the network by other users. f ) All communications and information accessible via the network should be assumed to be private property.

5. Network IntegrityNetwork personnel will be granted sufficient latitude to test for network security and Web-access filtering.

Student’s Name: Student’s Home Phone:

5

6. No WarrantiesThe Hawaii Technology Academy make no warranties of any kind, whether expressed or implied, for the service they are providing. HTA will not be responsible for any damages a user suffers. This includes loss of data resulting from delays, no-deliveries, misdeliveries, or service interruptions caused by HTA’s negligence or by user errors or omissions. Use of any information obtained via the Internet is at the user’s own risk. HTA specifically denies any responsibility for the accuracy or quality of information obtained through its services. All users need to consider the source of any information they obtain and consider how valid that information may be.

7. Securitya) Security on any computer system is a high priority, especially when the system involves many users. Users must never allow others to use their password. Users should also protect their password to ensure system security and their own privilege and ability to continue use. b) If you feel you can identify a security problem on the Internet, you must notify HTA. Do not demonstrate the problem to other users. c) Do not use another individual’s account (except network personnel in system setup and maintenance functions). d) Any user identified as a security risk for having a history of problems with other computer systems may be denied access to the Internet as provided by HTA.

8. Vandalism and Harassmenta) Vandalism and/or harassment will result in loss of user privilege. b) Vandalism is defined as any malicious attempt to harm, modify, and destroy data of another user. This includes, but is not limited to, the uploading or creating of computer viruses. c) Harassment is defined as the persistent annoyance of another user or the interference with another user’s work. Harassment includes, but is not limited to, the sending of unwanted e-mail.

9. Encounter of Controversial MaterialAlthough HTA provides a filtering system, users may encounter material that is controversial and that users, parents, teachers, or administrators may consider inappropriate or offensive. However, on a global network it is impossible to control effectively all content of data, and an industrious user may discover controversial material. It is the user’s responsibility not to initiate access to such material.

PENALTIES FOR IMPROPER USE:1. Any user violating these rules, applicable state or federal rules, or those posted by HTA, are subject to loss of network privilege and other potential HTA disciplinary options.

USER: I understand and will abide by the above Conditions, Rules, and Acceptable Use Agreement. I further understand that any violation of the above conditions, rules, and acceptable use agreement may be unethical and/or may constitute a criminal offense. Should I willfully commit any violation, my access privilege may be revoked, disciplinary action may be taken, and/or appropriate legal action taken.

Date:

Name (printed): first middle last

Signature:

Position: o Student o Staff o Administrator

IF UNDER 18 YEARS OF AGE, A PARENT/GUARDIAN SIGNATURE IS ALSO REQUIRED.

PARENT/GUARDIAN: As the parent/guardian of the above listed student, I have read and understand the Internet and Network User Agreement. I understand that this access is designated primarily for students under the age of 18 years, for educational purposes. I understand that HTA is taking reasonable steps to safeguard students from inappropriate material; however, access to such material is still possible. I WILL NOT hold HTA responsible for inappropriate materials accessed on the network.

Date:

Name (printed): first middle last

Signature:

Hawaii Technology Academy Network and Internet User Agreement Hawaii Technology Academy

Student’s Name: Student’s Home Phone:

6

Hawaii Technology Academy94-810 Moloalo Street 2nd Floor Waipahu, HI 96797

Ph. 1.808.671.3178Fx. 1.808.676.5470www.k12.com/hta

Home Language SurveyIn order to comply with state requirements, please answer the following questions about your child’s language. Thank you for your assistance. All your answers are for school purposes only.

Student’s Name: last first middle

Date of Birth: Place of Birth: City State Country

Address:

Phone: Cell:

DIRECTIONS: For each of the following questions, please fill in the appropriate letter from the list below. If “Other”, please fill in what language “Other” represents:

A – English B – Cantonese C – Mandarin D – Ilocano E - Tagalog F – Cebuano/Visayan G – Hawaiian H – Japanese I – Korean

J - Samoan K – Vietnamese M – Chuukese N – Pohnpeian O – Cambodian P - Chamorro Q – Fijian R – Hmong S – Lao

T – Marshallese U - Pampango V – Pangasinan W – Portuguese X – Spanish Y – Thai Z - Tongan L – Other (Specify):

1. Student’s first acquired language:

2. Language most often spoken at home:

3. Language most often used by the student:

Person Completing Form (please print)

Relationship to student

Parent/Guardian’s Signature: Date:

Student’s Name: Student’s Home Phone:

7

SELF-ADMINISTRATION OF MEDICATION FOR SY: _________A. Parent’s Request and Authorization

I, THE UNDERSIGNED, request and authorize my child __________________________ to self-administer his/her medication: inhaler auto-injectable epinephrine (EpiPen) while at school.

(Circle one or both as appropriate)

This authorization is given based on the following:• My child is capable of and has been instructed in the proper method of self-administration

of this medication.• I understand that my child shall be permitted to carry at all times his/her medication as

long as he/she does not endanger him/herself, or endanger other persons, and will notmisuse the medication.

• I understand that if my child misuses or exceeds the prescribed dosage, or endangers otherswith the medication, school employees or agents may confiscate the medication.

Parent/Guardian Signature: ________________________________ Date: _______________

I, THE UNDERSIGNED,• understand that the Department of Education, its employees or agents shall not incur any

liability as a result of any injury arising from the self-administration of the medication bymy child;

• shall exempt from liability and hold harmless school employees or agents against anyclaims arising out of the self-administration of medication by my child;

• understand that this authorization shall be effective for this current school year and must berenewed annually.

Parent/Guardian Signature: _____________________________ Date: __________________

B. Physician’s Certification

I, THE UNDERSIGNED, certify that _______________________________has asthma,(student’s name)

anaphylaxis or another related potentially life-threatening illness _____________________, and(specify)

he/she is capable of and has been instructed in the proper method of self-administration of

his/her own asthma and/or auto-injectable epinephrine (EpiPen) medication.(circle appropriate medication)

Physician’s Physician’sName: __________________________________ Signature: ___________________________

(type/print)Address: _________________________________ Telephone: __________ Date ____________

Reviewed/Accepted by: ___________________________ Date: _________________Principal or DOE Designee

Received by PHN/SHA: ___________________________________ Date __________________DOE: July, 2004 Inhaler and EpiPen Consent Form

MV1 State of Hawaii Department of Education HOMELESS CONCERNS OFFICE

475 22nd Avenue, Room 126 Honolulu, Hawaii 96816

Telephone: 808-203-5521 Toll Free: 1-866-927-7095 FAX: 808-735-8229

QUESTIONNAIRE TO DETERMINE ELIGIBILITY

McKinney-Vento Homeless Assistance Improvements Act

(�“MVA�”)

Schools are required

to keep a chronological file

of completed Questionnaires for each school

year.

STUDENT�’S NAME: ___________________________________________ SCHOOL: ____________________________ Section 1. Action Requested: (A copy of this form must be attached to each of the following forms.) Enrollment Geographical Exception* Exit, Release or Transfer Transportation (ONLY when a box in Section 3 is checked)

Section 2. Student / Parent / Guardian IS NOT in a homeless situation. If Section 2 is checked, stop and complete Parent/Guardian signature below; form is complete. Section 3. Does The Student / Parent / Guardian: (Check the box that applies – you may be eligible for services)

Live with friends or family due to economic hardship such as loss of housing or income; Live on the beach, at a campground, in a park, or in a hotel; Live in a tent, car, bus, or other non-permanent structure; Live in a domestic violence shelter; Live in an emergency or transitional shelter: (Please circle or if your shelter is not listed, please write in the name.)

Kaua`i: Manaolana, Kuapo, Other___________________;

Hawai`i: Kihei Pua, Beyond Shelter, Kaloko Transitional, Other_____________________;

Maui: Ho`olanani, Ka Hale A Ke Ola, Ka Hale A Ke Ola - Westside, Other _____________________;

O`ahu: Family Promise, Institute for Human Service (IHS), Loliana, Ohana Ola O Kahumana, Maililand, Next Step, Vancouver House, Onemalu, Onelauena (Hope for a New Beginning), Pai`olu Kaiaulu (Waianae Civic Center), Weinberg Village Waimanalo, Ulu Ke Kukui (Villages of Maili), Ka Ohu Hou o Manoa, Lighthouse Shelter, Kahi Koulu Ohana Hale O Wai`anae, Other_______________________________

Have no regular place to stay at night. The student is awaiting foster care. The student is an unaccompanied youth.

____________________________ _________________________ ______________ Parent / Guardian Signature Print Name Date

When any box in Section 3. �“Does The Student / Parent / Guardian:�” is checked, the student may be eligible to receive MVA services. School personnel are to assist the parent, guardian or unaccompanied youth with the completion of the reverse side of this form and the McKinney-Vento Act (MVA) School Packet.

___________________________ __________________________ ______________ DOE Representative�’s Signature Print Name Date * Geographical exceptions apply to MVA eligible students ONLY WHEN there is a request to have the student attend a school other than the student’s school of origin or home school.

This questionnaire is intended to address the McKinney-Vento Act (42 U.S.C. 11434a(2)). The answers provided help determine appropriate and comparable MVA services.

All collected information will only be used for the purposes of providing educational services pursuant to the McKinney-Vento Act and is protected by federal and state laws.

MV1 - REV 3/2012

Section 4. Name of School: _____________________________________________________________________________________

Student Name: _________________________________________________________ _____Male _____Female

Date of Birth________/________/__________ Grade_______ Student ID# __ __ __ __ __ __ __ __ __ __

Section 5. Is current residence a temporary living arrangement? _____NO _____YES, for______Months______Years

If the answer is NO, you may stop here. If the answer is YES, please complete the remainder of this form.

Section 6. Student is living with family or friends due to economic hardship such as:

_____Loss of Housing _____Loss of Income _____Other:______________________________________

Address:__________________________________City:_______________________Telephone:_______________________________

Section 7. Student is applying for the following:

_____Free/Reduced-Price Meals _____Transportation to and from school (when feasible) _____Other:___________________________

NOTE: Services provided will be comparable to services provided to all other students attending this school. Section 8. Parent or Guardian, please initial agreement to the following:

_____YES. I understand and agree that the Homeless Concerns Liaison may contact me.

_____I will immediately inform the school administrator in writing if any changes occur to this information.

Signature of Parent or Guardian:_________________________________________Telephone:___________________Date:___________

Section 9. For School Use Only

_____Home School (school within the geographic area of student�’s current residence)

_____School of Origin (school attended when permanently housed / last school attended)

_____GE

_____Other_____________________________________________________

PRINT Name of School Representative:___________________________________Title:______________________

Signature of School Representative: ______________________________________Date:_____________________

By signing above, the school representative acknowledges that the parent or guardian has been provided with MVA information and a copy of this form.

MV1 - REV 3/2012

EMERGENCY CARD (This card needs to be completed every school year)

School: Hawaii Technology Academy Date: __________________ Grade: ___________

Language Spoken at Home ___________________________________________________________

Name ________________________________________________________________________________________ (Last) (First) (Middle Initial)

Sex: M___ F___ Birthdate ______________________________________ (ie. 09/01/2000) (Month) (Day) (Year)

Home Address _________________________________ Apt. No. _________ City _____________________Zip Code _____________

Child resides with ____________________________________________________________________________________________________

Mailing Address _____________________________________________________ City __________________Zip Code ______________

EMERGENCY CONTACTS: In case child listed above becomes ill or is injured at school and I cannot be contacted, the school authorities have my permission to contact and release my child to the custody of one of the following: Name Relationship Phone

1. _____________________________________________________ ________________________________ ________________________

2. _____________________________________________________ ________________________________ ________________________

3. _____________________________________________________ ________________________________ ________________________

If my child needs to be taken to an emergency facility, she/he will be taken to the nearest one. I give my consent for school authorities to take appropriate action for the safety and welfare of my child. _________________________________________________________________________________ Parent’s/Guardian’s Signature

To assure prompt attention to your child, PLEASE NOTIFY HTA OF ANY CHANGE IN PHONE NUMBER, ADDRESS, OR EMAIL.

My child received regular care for the following medical conditions:

_____ No medical condition _____ Yes. Please check below ___Asthma ____ Chronic Cough/Wheezing _____Heart Disease _____JRA Arthritis _____ Sickle Cell Anemia ____Behavioral Problems _____ Cancer/Leukemia

___Diabetes _____Hemophilia ___ Rheumatic Heart ______Skin Problems _____Hearing Problem ______Hypertension ______ Seizures _______ Vision Problems

_____Allergies: ____ Bee Sting ____ Food ____ Medications ____Other: __________________________________________________________________________

Date and type of last reaction: __________________________________________________________________________________________________________________

_____Other Health Concerns: __________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________

___Takes Medications (LIST): ____________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________

*Other Children: NAME SCHOOL GRADE

_________________________________________________ ________________________________________ ________________________________

_________________________________________________ ________________________________________ ________________________________

_________________________________________________ ________________________________________ ________________________________

_________________________________________________ ________________________________________ ________________________________

Selection Required: Oahu Hawaii/HILO Hawaii/KONA Kauai Maui (non-Hana) Maui/Hana Molokai

Lanai

Mother’s/Guardian’s Name

________________________________________________________________________

Employer ____________________________________________________________

Cell Phone____________________________________________________________

Bus. Phone ______________________ Home Phone _____________________

Email address ________________________________________________________

Father’s/Guardian’s Name

________________________________________________________________________

Employer ____________________________________________________________

Cell Phone____________________________________________________________

Bus. Phone ______________________ Home Phone _____________________

Email address ________________________________________________________

My child has health insurance: ______Yes ______No If YES, check _______QUEST/Medicaid OR _____ Private Check Plan: _____HMSA _____Kaiser _____Tri-Care ___Other

Form SP/VR

State of Hawaii Department of Education

Student Publication/VideoRelease Form

This form combines and replaces the previous Student Permission to Videotape/Record and

Reproduce Work Forms. By signing this form, you agree to the terms and conditions of this

agreement. Please complete the following:

1. Print all of the following legibly. Use blue or black ink.

2. Check the boxes below.

3. Sign this form.4. Distribute as instructed.

I hereby give my permission to the Hawaii State Department of Education (HIDOE) to use my child’s work,videotape, or otherwise record my child’s name, voice, and/or likeness in its publications. I understand that

examples of my child’s work and/or these recordings of my child will be used exclusively for non-commercial,

educational purposes, which may include, but not limited to, distribution by print, internet, or digital media and

open-circuit broadcast, closed-circuit, and/or cable television transmission within or outside of the State ofHawaii for the duration of the media.

I understand that there will be no financial or other remuneration for use of my child’s work and/or recordings,either for initial or subsequent transmission or playback, and I hereby release the HIDOE from any liability

resulting from or connected with the publication of such work. Permission is granted for the duration of the

media. I further understand that my permission or consent may be rescinded; however, in order for therevocation of permission/consent to be effective, it must be made in writing and said revocation will not affect

the publication or work that has already been produced.

The HIDOE may use my child’s name, likeness, work, and/or bibliographical identification for publicizing andpromoting the use of these recordings.

The HIDOE has permission to videotape or otherwise record my child’s name, voice, and/or likeness foreducational purposes.

� yes � no

The HIDOE has permission to use my child’s work for educational purposes.

� yes � no

Student’s Name (Please Print)

School

Home Address

City, State, Zip Code

Parent/Guardian Name (Please Print)

Signature

Date

Distribution: White: School Canary: Parent

Student Publication/Video Release Form RS 07-0116