New Student Enrollment Packet 2015-2016 School Year

Please process your packet and return now. Read all instructions carefully.

1. Student Information Form – EN1: You MUST use the student’s LEGAL NAME as

shown on the birth certificate or adoption papers. We need all the information requested. There are three questions concerning language spoken. Please read them carefully. We want to be sure all students requiring services for English as a Second Language (ELL) receive them.

2. Home Language Survey – Form EN1a: This form is required by the Federal Government, and will assist the school in determining what, if any, English Language Learner services may be helpful in creating the most positive learning environment for your student.

3. Household Form – EN2: We are requesting both a mailing address and street

address; if they are different please give us both. We are requesting home, work, and cell phone numbers. It is important to have a number to reach an adult in case of an emergency. If either parent is on active duty military, please make sure to include rank (E-3, O-1, etc.) and unit information (A Company, 101st, etc.), and military ID expiration date.

4. Emergency Contacts Form – EN3: This form is used to identify non-household

members who are emergency contacts for your student. Please list someone who is local. Remember if we do not have people listed, they may not pick up your child.

5. Residency & Employment Questionnaire – ER1: This form addresses the

McKinney-Vento Act and Migrant Education Program. It will help determine services that may be available for your student.

6. Parking Permit Letter and Form: All vehicles must be registered in order to park in

JCHS lots. Complete the enclosed permit form and return with the following documents: proof of insurance, registration, and driver’s license, to obtain a permit. The first permit is free, and each additional permit is $5.00. Permits are non-transferable; each car must have its’ own permit.

7. Fee Assessment Form: The enrollment fee is $20.00 and must be paid at the time of

enrollment. If paying by check or money order, please make payable to Junction City High School, and include student’s name and phone number in the memo section. Postdated checks will not be accepted.

8. Child Nutrition Reduced Price/Free Application: The Child Nutrition Free Lunch

Application can be obtained from the Food Service Secretary at JCHS.

9. Parent Release of Information: This is a release the district may submit to Medicaid if your child receives certain, specific health related services through the district.

10. Student Health Information Form – EH1: This form needs to be completed each year

for each student, even if they do not have a health concern. Complete front and back of this form.

11. JCYC Information Letter: A letter regarding the health services the Junction City

Youth Clinic provides. Junction City High School Blue Jay Club (After School Program)/Army Youth Programs in Your Neighborhood (AYPYN): For information call 785-717-4025 or email jamesrussell@usd475.org.

USD 475 Student Information Form – EN1

Student Legal Name (as shown on Birth Certificate)

(Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Gender: M F Birth Date Grade Nickname

(circle one)

School student previously attended

Last year attended City State

Has the student previously been enrolled in a Kansas school? Yes No

If so, name of school City

Important Questions (Please answer the following questions)1. Was this student born in the United States? Yes No

2. Has this student attended a school outside the United States in the past 3 years? (excluding DOD schools)

Yes No

3. What date did this student Enter the US?

4. What date did this student enter a US School?

5. Does this student have an Individual Education Plan (IEP)? Yes No

6. Has this student been involved in a program for Gifted/Talented through school? Yes No

7. Does this student have a 504 Plan? Yes No

Race and Ethnicity (BOTH questions must be answered)

1. Is this student Hispanic/Latino? (Choose only one)

No, Not Hispanic/Latino

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

2. What is the student’s race? (Choose one or more)

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) If this student did not attend this school, please answer the following:

****************************************** For Office Use Only *******************************************

Teacher: Start Date: School Fees:

Lunch Code: Bus Route: Sec8003:

Student Number: Building:

USD 475 Student Information Form – EN1a

HOME LANGUAGE SURVEY Upon enrollment, every student or parent/guardian must be given a Home Language Survey. This survey will be used to determine which students should be assessed for English proficiency. Knowledge of, or exposure to another language does not, in and of itself, qualify a student for ESOL services. If a language other than English is indicated in any of questions 1-4, the student will be assessed to determine eligibility for English for Speakers of Other Languages (ESOL) services. The assessments approved by Kansas State Department of Education include: The Language Assessment Scales (LAS)/LAS LINKS/Pre-LAS, the IDEA Proficiency Test (IPT)/Pre-IPT, the Language Proficiency Test Series (LPTS), and the Kansas English Language Proficiency Assessment (KELPA)/KELPA-P. If a student scores below proficient/fluent in any of the language domains: listening, speaking, reading, or writing, s/he is eligible for ESOL services. Please complete one form for each child. Student Information: Name _______________________________________________Grade__________ Address_______________________________________________________ Date of Birth___________ Date first enrolled in a school in the U.S._______________ Phone Number________________________ Student Language Information: 1. What language did your child first learn to speak/use?

English ______ Spanish ______ Other (please specify) ________________ 2. What language does your child speak/use at home? Do not include language learned in a class or through television or other such programming.

English ______ Spanish ______ Other (please specify) ________________ 3. What language do you speak/use with your child?

English ______ Spanish ______ Other (please specify) ________________ 4. What language do the adults regularly present or living in the home speak/use while in presence of the child?

English ______ Spanish ______ Other (please specify) ________________ Parent/Guardian Information: Which language do you prefer? English ___Spanish ___ Other (specify)______________ (Please specify “written” or “spoken”. To the extent practicable, communication from the school will be provided in this language.) Migrant Education Program Information: The Migrant Education Program (MEP) is authorized by Title I Part C of the Elementary and Secondary Education Act of 1965 (ESEA). The MEP provides formula grants to local education agencies to establish or improve education programs for children who may qualify for the Migrant Program. Please help us determine your child’s eligibility for the Migrant Program by responding to the following questions. Has your family moved in the last 36 months to seek or obtain agriculture or fishing related work?

Yes _____No _____ If yes, was the move from one school district to another? Yes _____ No _____ For the School: If the answer to either of the previous two questions is Yes, please provide a copy of this form to the district Migrant Education Coordinator, Marty Rombold at Lincoln School. _______________________________________ _________________________ Signature of Parent or Guardian Date

Home Phone

Home Address (Number) (Street) (Apt/Lot) (City) (Zip Code) (County)

Mailing Address (only if different from home address) (Number) (Street) (Apt/Lot) (City) (Zip Code) (County)

Student Lives With (Please select one)

Both Parents Mother Only Father Only Each Parent Alternately Parent & Step Parent Legal Guardian

Household Relationships

Guardian’s Relationship

(Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Cell Phone Email

Current Employer Work Phone

Civilian employed on Fort Riley? Yes No Military on Active Duty? Yes No Branch of Service Military Unit Rank (Army, Navy, etc.) (A Company, 101st, etc.) (E-3, O-1, etc.)

Military ID expiration date: (Please use mm/dd/yyyy format.)

Guardian’s Relationship

(Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Cell Phone Email

Current Employer Work Phone

Civilian employed on Fort Riley? Yes No Military on Active Duty? Yes No Branch of Service Military Unit Rank (Army, Navy, etc.) (A Company, 101st, etc.) (E-3, O-1, etc.)

Military ID expiration date: (Please use mm/dd/yyyy format.) Please list ALL children enrolled in District and live at the above address (Name, Grade, and Building):

1. 2. 3. 4. 5. 6.

USD 475 Household Information Form – EN2

Note: If parents/guardians live in separate homes, please fill out one form for each household.

1. Emergency Contact Name (Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Emergency Contact’s Gender M F Relationship to student (circle one)

Home Phone Work Phone

Cell Phone

2. Emergency Contact Name

(Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Emergency Contact’s Gender M F Relationship to student (circle one)

Home Phone Work Phone

Cell Phone

3. Emergency Contact Name

(Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Emergency Contact’s Gender M F Relationship to student (circle one)

Home Phone Work Phone

Cell Phone 4. Emergency Contact Name

(Last Name) (First Name) (Middle Name) (Suffix, e.g. Jr. II)

Emergency Contact’s Gender M F Relationship to student (circle one)

Home Phone Work Phone

Cell Phone

USD 475 Local Emergency Contacts Information Form – EN3This form is to identify non-household members (other than parents and guardians) who are the LOCAL emergency contacts for each of your students. Please use FULL names of emergency contacts.

USD 475 Student Information Form – ER1

The answers to this document, which addresses the McKinney-Vento Act and Migrant Education Program, will help determine services that may be available to your student. Student Name______________________________________________________ School________________________________ Student Grade ______ Date of Birth ____________________ Male ___ Female ___ Military Student? Yes__ No___ Parent/Guardian(s)________________________________________________________________Phone____________ Present Address _________________________________________________City ___________________ State____ Zip _________ Last School Attended _____________________________________________City __________________________ State ________ Is your current address a temporary living arrangement? Yes _______ No, I am in stable housing _______

If YES, have you recently lost your housing or experienced an economic hardship? Yes _____ No______

Within the last 3 years, we have done seasonal migratory work. Yes _____ No _____ If you answered YES to any of the above, please COMPLETE THE REMAINDER OF THE FORM.

Section A Living Arrangements (Must Select One)

Temporarily with another family (due to loss of job, loss of housing, etc.)

In a motel/hotel

In a shelter

Unsheltered (campgrounds, cars, parks, or other place not designed for permanent housing) or substandard housing Independent Living Student (Check if Applicable) Alone without parental support (student living independently)

Section B

Within the last 3 years, we have done seasonal migratory work? Yes____ No_____ If Yes, please identify: Temporary laborer harvesting crops Location: _________________________________________________________ Temporary farm, poultry or dairy labor Location:______________________________________________________ Temporary greenhouse or nursery work Location:______________________________________________________

I certify by my signature that the above information is accurate. ________________________________________________ ________ ________________________________________ Parent/Guardian Signature Date

ATTENTION SCHOOL PERSONNEL: If Sections A or B are checked, please forward the completed form to Marty Rombold, Lincoln Elementary School, 300 Lincoln Drive, Junction City or fax to her attention at (785)717-4571.

JUNCTION CITY HIGH SCHOOL900 N. Eisenhower Dr ▪ Junction City, KS 66441 ▪ (785) 717-4200 (0)  

JCHS Student Parking Permit Registration 

 

The operation and parking of a motor vehicle on the JCHS campus is a privilege for licensed student drivers.  

As such, students are expected to follow all rules and regulations of the parking lot to include no parking 

areas such as: staff parking, visitor parking, fire lanes, and drop off areas.  Improper parking or unsafe 

driving may result in loss of campus parking privileges. 

 

Any vehicle parked on campus during the school day must have a Junction City High School parking permit on 

the lower right corner of the rear passenger windshield.   

 

Please complete this form, and provide copies of your driver’s license, registration and car insurance to Mrs. 

Martin in Rm. 101 for your parking permit. The first permit is free; additional and/or replacement permits 

are $5.00 each.   

 

****Student parking is located in the north lots (upper and lower). 

 Student Name__________________________________________________Grade_________Ph#_________________________ Driver’s License #________________________________________    Academy_________________  

 If the Vehicle already has a JCHS Permit, Write it & vehicle info below. 

Year   Make  Model  Color  License Plate # 

Vehicle Permit  #1           

Vehicle Permit  #2           

Vehicle Permit  #3           

Vehicle Permit  #4           

  For office use only:    Date Registered______________________________   Staff Name__________________________  

Revised 4/14/2015 

   

USD 475 Fee Assessment Form 2015-2016 Enrollment Fee Statement

Student Name Grade

Enrollment Fee $20.00

Note: Enrollment fees must be paid at the time of enrollment. If paying by check or money

order, please make payable to Junction City High School, and include your student’s name and phone number on the memo section.

Freshmen Success Academy ● Business and Information Technology Academy ● Fine Arts and Human Services Academy ● Science, Engineering and

Technology Academy

Geary County Unified School District 475 Mary E. Devin Center for Education Support

PO Box 370 - 123 N. Eisenhower - Junction City, KS 66441-0370 (785) 717-4000 Fax (785) 717-4003 www.usd475.org

DATE: May 2015

MEMO TO: Parents/Guardians

FROM: Dr. Corbin Witt Superintendent of Schools

SUBJECT: Child Nutrition Reduced Price/Free Application

The following forms will be sent to all households 4 weeks before the start of school.

Child Nutrition and Fee Assessment Application for Child Nutrition Program Benefits (Free and Reduced Lunch) Free Textbook Waiver Form Application for Free Textbooks

If your student has a food allergy, intolerance, or special dietary need that requires modification of the school menu, please pick up the Medical Statement for Student Requiring Special Meals Due to Food Allergy or Intolerance form at your student’s school.

Parent Release of Information

Student Name: _________________________________________ DOB:__________________________ Permission is given for the Geary County Unified School District to share appropriate information concerning the above listed student with the Kansas Health Policy Authority so the Geary County School District, can, if applicable, seek reimbursement for any health-related services that are claimable under the Title XIX Medicaid. In conjunction with the above, I understand that the Geary County Unified School District also needs to obtain a “Physician’s Prescription” for some/all of the health-related services that is provided to the student. In this regard, I hereby give permission for the Geary County Unified School District, if applicable, to share portions of the student’s Individual Education Plan (IEP) with a qualified health care professional in order to obtain such “Physician’s Prescriptions”. Physicians Name: _____________________________________________________________ Contact Information: __________________________________________________________ I understand that the Geary County Unified School District is required to provide certain health-related services to any student who has an IEP at no additional cost to the student’s parent(s)/guardian(s). I also understand that my signature- or failure to sign this form- will not affect whether such services are provided to the student. I understand all of the statements set forth above – and I hereby grant all of the above. I also understand that if no response/permission is obtained from the health care provider above, this consent form will be sent to the current USD 475 contractor for Medicaid services. PARENT(S)/GUARDIAN(S) SIGNATURE(S) _______________________________________ DATE_____________ Geary County Unified Schools Exceptional Student Services Division 123 N. Eisenhower Junction City, KS 66441 Ph#: (785)717-4091 Fax#: (785)717-4002 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

PHYSICIAN AUTHORIZATION

Dear Health Care Provider: As specified in the student’s, Individual Education Plan (IEP), the student qualifies to receive one or more of the following services during the time period that is specified in that IEP. Audiology Occupational Therapy Physical Therapy Nursing Services Speech/Language Therapy Psychological Testing/Social Work Services If/as appropriate, the Geary County Unified School District may seek reimbursement from the Kansas Health Policy Authority for some/all of the above-listed services. In order to do that, however, the Geary County Unified School District must obtain the signature of a qualified health care provider. Your signature certifies that the student qualifies to receive some/all of the above-listed services that are specified in the student’s IEP. In this regard, this document will serve as the required “Physician’s Prescription” with respect to those services. PHYSICIAN SIGNATURE_______________________________________Date_____/_____/_____

PARENTS/GUARDIANS: This form must be completed (BOTH SIDES) each year and returned to the school nurse.

STUDENT HEALTH INFORMATION FORM ENVELOPE PROVIDED MAIL-IN ENROLLEES

Student Name_____________________________________________Birth Date_____________Grade_____Date___________________

Does this student: 1. Have a medical diagnosis of a

current or chronic health problem (such as diabetes, tuberculosis, seizures, cystic fibrosis, asthma, muscular dystrophy, digestive disorders, etc.)

Condition_________________________ Physician_________________________

Yes No Parent/Guardian Comments Health Room Staff Notations

2. Receive ongoing medication for conditions (ADHD, allergies, asthma, diabetes, depression, anxiety, etc.)

Medication________________________ Dosage___________________________ Time Administered_________________ Reason for giving__________________ ( Fill out Medication Permission form if it needs to be taken at school.)

May carry and self-administer emergency medication (inhalers and epinephrine) with school form signed by health care provider. HIGHLY RECOMMENDED FOR STUDENTS IN SPORTS/ACTIVITIES. Health Forms and medication guidelines on USD475.org Health Services website or from school nurse.

3. Known allergies ( food, pollen, animals, medicine, etc)

________________________________ ________________________________

4. Hearing Concern: Known Condition:__________________ Wears Hearing Aid: Yes_____ No_____ Date of last hearing exam:____________

5. Vision Concern Wears glasses/contacts: Yes____No____ Date of last eye exam:_______________

6. Special instructions for activities, dietary, restroom, etc.

_________________________________ _________________________________

Need health care provider order to modify Physical Education requirements

GEARY COUNTY YOUTH CLINIC PARENT/GUARDIAN CONSENT FORM

The school nurse has my permission to release_________________________________________ to the Junction City Youth Clinic for the purpose of obtaining health services. (Name of Student) Signature_________________________________________ Date______________________________ (Parent/Guardian) Home Phone_______________________________ Business Phone________________________________

---------Permission/Release Statements--------- I give my consent for my child’s immunization information to be released to the Kansas Immunization Program for the purpose of assessment and reporting. ________________________________________ __________________ Signature of Parent/Guardian Date I give consent for my child’s immunization information to be shared with/obtained from other schools or health care providers/clinics for the purpose of meeting school health requirements. _______________________________________ ___________________ Signature of Parent/Guardian Date

The following information is requested to help provide parents with accurate information about obtaining health care services:

Type of Health Insurance: Tri-Care _______ Private _______ None _______

KanCare (Amerigroup, Sunflower or United Health) _______ Type of Dental Insurance: KanCare _______ Private _______ None _______ MetLife (purchased for military dependents) _______ Student’s Doctor _______________________________________________________ Student’s Dentist _______________________________________________________

Junction City Youth Clinic Health Department

1212 West Ash Street P.O. Box 282

Junction City, Kansas 66441

Board Members Patricia Hunter, BSN Administrator Board Members Joyce McRae Chair Ronald Mace, M.D. Medical Director Mike Ryan City Commissioner Larry Hicks County Commissioner Kenneth Bellamy Mary Burnham Lucy Gonzalez Telephone: 785-762-5788 Facsimile: 785-762-1311 Website: www.jcgchealthdept.org

Dear Parents: The Junction City Youth Clinic was established to provide low-cost healthcare services for students of USD 475 and children and adolescents ages 0 to 21 of Geary County, allowing students to be seen by a clinician and then return to classes without missing a full day of class unless a referral is required. In order to serve more individuals, we have become a Blue Cross/Blue Shield contracted provided and are requesting your assistance. Many students are sent directly to the Youth Clinic by the school nurse to be seen by our KU Practice Resident Physician and/or our Advanced Registered Nurse Practitioner (ARNP) for minor illnesses. We are charging a minimal fee for the services provided to our youth and request that you please provide insurance information for billing purposes. If there is no medical card such as Medicaid or Blue Cross Blue Shield, we will be sending an invoice to the address provided by the student for services. If no insurance is available, a donation for the services provided is requested. Please notify the office of the Youth Clinic at 785-762-5022 with any insurance information. If no insurance is available, please submit payment. With your assistance, the Youth Clinic will continue to provide healthcare services on an as needed basis to the children and adolescents of our community. Sincerely, Patricia Hunter Administrator

Junction City Youth Clinic (JCYC)

Information: A fee of $20.00 is required for sports physicals. Sports physicals are valid beginning

May 1st proceeding the school year they are needed. Appointments are required for all physicals.

If a student is referred to another facility, arrangements need to be made by the

parent/guardian for any additional costs. JCHS students will be released to the clinic during school hours only if a

parental/guardian consent form is on file with the school nurse. (Consent form is on the bottom of the Student Health Information Form.) Students without written consent form are welcome to visit the clinic before school, during lunch and after school.

A fee is charged for services. If there is no medical card such as Medicaid, Health Wave,

or Blue Cross, an invoice will be sent to the address provided by the student for services. If no insurance is available, a donation for the services provided is requested. (See reverse side of paper for letter from the clinic.)

The Junction City Youth Clinic is located at 1018 West 6th Street. The Clinic is in

walking distance from the Junction City High School. Contact the Clinic at 762-5022 for more information or to schedule an appointment. By signing the bottom of the JCHS Health Form, you are granting permission for your student to be sent to JCYC.

A n n u a l N o t i c e o f A u t h o r i z e d S t u d e n t D a t a D i s c l o s u r e s

I n a c c o r d a n c e w i t h t h e S t u d e n t D a t a P r i v a c y A c t a n d b o a r d p o l i c y I D A E , s t u d e n t d a t a s u b m i t t e d t o

o r m a i n t a i n e d i n a s t a t e w i d e l o n g i t u d i n a l d a t a s y s t e m m a y o n l y b e d i s c l o s e d a s f o l l o w s . S u c h d a t a m a y b e

d i s c l o s e d t o :

T h e a u t h o r i z e d p e r s o n n e l o f a n e d u c a t i o n a l a g e n c y o r t h e s t a t e b o a r d o f r e g e n t s w h o r e q u i r e d i s c l o s u r e s

t o p e r f o r m a s s i g n e d d u t i e s ; a n d

T h e s t u d e n t a n d t h e p a r e n t o r l e g a l g u a r d i a n o f t h e s t u d e n t , p r o v i d e d t h e d a t a p e r t a i n s s o l e l y t o t h e

s t u d e n t .

S t u d e n t d a t a m a y b e d i s c l o s e d t o a u t h o r i z e d p e r s o n n e l o f a n y s t a t e a g e n c y , o r t o a s e r v i c e p r o v i d e r

o f a s t a t e a g e n c y , e d u c a t i o n a l a g e n c y , o r s c h o o l p e r f o r m i n g i n s t r u c t i o n , a s s e s s m e n t , o r l o n g i t u d i n a l r e p o r t i n g ,

p r o v i d e d a d a t a - s h a r i n g a g r e e m e n t b e t w e e n t h e e d u c a t i o n a l a g e n c y a n d o t h e r s t a t e a g e n c y o r s e r v i c e p r o v i d e r

p r o v i d e s t h e f o l l o w i n g :

p u r p o s e , s c o p e a n d d u r a t i o n o f t h e d a t a - s h a r i n g a g r e e m e n t ;

r e c i p i e n t o f s t u d e n t d a t a u s e s u c h i n f o r m a t i o n s o l e l y f o r t h e p u r p o s e s s p e c i f i e d i n a g r e e m e n t ;

r e c i p i e n t s h a l l c o m p l y w i t h d a t a a c c e s s , u s e , a n d s e c u r i t y r e s t r i c t i o n s s p e c i f i c a l l y d e s c r i b e d i n

a g r e e m e n t ; a n d

s t u d e n t d a t a s h a l l b e d e s t r o y e d w h e n n o l o n g e r n e c e s s a r y f o r p u r p o s e s o f t h e d a t a - s h a r i n g a g r e e m e n t

o r u p o n e x p i r a t i o n o f t h e a g r e e m e n t , w h i c h e v e r o c c u r s f i r s t .

* A s e r v i c e p r o v i d e r e n g a g e d t o p e r f o r m a f u n c t i o n o f i n s t r u c t i o n m a y b e a l l o w e d t o r e t a i n s t u d e n t

t r a n s c r i p t s a s r e q u i r e d b y a p p l i c a b l e l a w s a n d r u l e s a n d r e g u l a t i o n s .

U n l e s s a n a d u l t s t u d e n t o r p a r e n t o r g u a r d i a n o f a m i n o r s t u d e n t p r o v i d e s w r i t t e n c o n s e n t t o d i s c l o s e

p e r s o n a l l y i d e n t i f i a b l e s t u d e n t d a t a , s t u d e n t d a t a m a y o n l y b e d i s c l o s e d t o a g o v e r n m e n t a l e n t i t y n o t s p e c i f i e d

a b o v e o r a n y p u b l i c o r p r i v a t e a u d i t a n d e v a l u a t i o n o r r e s e a r c h o r g a n i z a t i o n i f t h e d a t a i s a g g r e g a t e d a t a .

“ A g g r e g a t e d a t a ” m e a n s d a t a c o l l e c t e d o r r e p o r t e d a t t h e g r o u p , c o h o r t , o r i n s t i t u t i o n a l l e v e l a n d w h i c h c o n t a i n s

n o p e r s o n a l l y i d e n t i f i a b l e s t u d e n t d a t a .

T h e d i s t r i c t m a y d i s c l o s e :

S t u d e n t d i r e c t o r y i n f o r m a t i o n w h e n n e c e s s a r y a n d t h e s t u d e n t ’ s p a r e n t o r l e g a l g u a r d i a n h a s

c o n s e n t e d i n w r i t i n g ;

d i r e c t o r y i n f o r m a t i o n t o a n e n h a n c e m e n t v e n d o r p r o v i d i n g p h o t o g r a p h y s e r v i c e s , c l a s s r i n g s e r v i c e s ,

y e a r b o o k p u b l i s h i n g s e r v i c e s , m e m o r a b i l i a s e r v i c e s , o r s i m i l a r s e r v i c e s ;

a n y i n f o r m a t i o n r e q u i r i n g d i s c l o s u r e p u r s u a n t t o s t a t e s t a t u t e s ;

s t u d e n t d a t a p u r s u a n t t o a n y l a w f u l s u b p o e n a o r c o u r t o r d e r d i r e c t i n g s u c h d i s c l o s u r e ; a n d

s t u d e n t d a t a t o a p u b l i c o r p r i v a t e p o s t s e c o n d a r y e d u c a t i o n a l i n s t i t u t i o n f o r p u r p o s e s o f a p p l i c a t i o n

o r a d m i s s i o n o f a s t u d e n t t o s u c h p o s t s e c o n d a r y e d u c a t i o n a l i n s t i t u t i o n w i t h t h e s t u d e n t ’ s w r i t t e n

c o n s e n t .

A s t h e p a r e n t o r l e g a l g u a r d i a n o f [ n a m e o f s t u d e n t ( s ) ] , I a c k n o w l e d g e t h a t I h a v e b e e n p r o v i d e d

w i t h n o t i c e o f a u t h o r i z e d s t u d e n t d a t a d i s c l o s u r e s u n d e r t h e S t u d e n t D a t a P r i v a c y A c t .

P a r e n t S i g n a t u r e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5 Questions: (Please initial next to each one you authorize for your student.) _____I authorize this student’s information to be distributed for the purposes of Military usage. _____I authorize this student’s information to be distributed for the purpose of Higher Education. _____I authorize this student’s information to be distributed for the purpose of Public usage. _____I authorize this student’s information to be distributed for the purpose of District usage. _____I authorize this student’s information to be distributed for the purpose of Local usage. S T U D E N T N A M E _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _