Education Empowerment Packet

Education Empowerment Packet

Purpose: This packet collects enrollment, emergency, medical, consent, and policy acknowledgments required for participation in educational programs and activities provided by the institution. Complete all sections fully and sign the certification at the end. Incomplete or inaccurate information may delay enrollment or program services.

Student Information

Date of Birth:    Student ID (if assigned):

Primary Phone:    Email:

Parent / Guardian Information (if student is under 18)

Relationship to Student:    Primary Phone:

Program Enrollment & Fees

Program Start Date:    Anticipated End Date:

Full payment    Monthly installments    Scholarship or financial aid applied

Emergency & Health Information

Relationship:    Phone:

Does the student have medical conditions or allergies that staff should be aware of? Yes No

Permissions and Consents

Field Trip Participation Consent: I consent to allow the student to participate in supervised off-site program activities. I do not consent

Photography / Media Release: I authorize use of student images and work for program materials and educational publicity. I do not authorize use

Administration of Medication or Emergency Treatment: I authorize program staff to administer prescribed medication and seek emergency medical treatment if necessary. I do not authorize

Academic Policies & Data Use

Academic Conduct: The student and guardian acknowledge responsibility to adhere to program academic standards, attendance expectations, and behavior policies. Repeated violation of policies may result in suspension or dismissal from the program.

Data Use and Confidentiality: Program records, progress reports, and contact records will be maintained for educational and administrative purposes. Records will be shared only with authorized personnel and with third parties as authorized below or as required by law.

Consent to Release Educational Records: I authorize release of educational records to the following named individuals or organizations for purposes of coordination of services:

Technology & Communication

Technology Acceptable Use: The student and guardian agree that the student will comply with technology use policies, including appropriate use of devices, networks, and online conduct. Unauthorized or unlawful use may result in loss of access privileges and disciplinary action.

I acknowledge I have read and accept the Technology Acceptable Use policy: Acknowledged

Certification and Signatures

Certification: I certify that the information provided in this packet is true and complete to the best of my knowledge. I agree to notify the program promptly of any changes. By signing below I authorize the institution to act on the consent items I have indicated above and acknowledge that I have reviewed relevant program policies.

Relationship to Student (if signer is not the student):

By signing, the signer affirms they are authorized to provide the consents indicated and understands that false statements may subject the signer to program sanctions and legal penalties where applicable.

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