Student Annual Signature Page

STUDENT ANNUAL SIGNATURE PAGE

Student Information

Student Name:   Date of Birth:

Student ID:   Grade / Program:   School Year:

Homeroom / Teacher:

Parent / Guardian Information (if student is a minor)

Emergency Contact & Medical Information

Annual Acknowledgements and Consents

I acknowledge that I have received, reviewed, and understand the Student Handbook and Code of Conduct. I agree that the student will comply with all school policies, rules and disciplinary procedures described therein. I understand that failure to comply may result in disciplinary action consistent with school policy.

I acknowledge the district's acceptable use policy for technology resources. I understand that misuse of electronic resources may result in suspension of access and/or disciplinary action. I accept responsibility for supervising the student's use of technology consistent with school expectations when access is provided at home.

I grant permission for the student to be photographed, interviewed, videotaped, or otherwise recorded for school-sponsored educational and informational purposes. I understand such materials may be used in publications, school social media, promotional materials, or educational projects unless I instead check the denial box below.

I do NOT grant permission for the student to be photographed, interviewed, videotaped, or otherwise recorded for school-sponsored publications or media.

I consent to my child's participation in regular school transportation services and authorize school personnel to transport the student on approved field trips in accordance with school policies. I understand separate permission may be required for certain off-site activities.

I authorize school personnel to administer or assist with student medication or emergency medical procedures as described in school policy and any individualized healthcare plans provided to the school. I understand that trained staff will follow written instructions from a licensed prescriber when applicable.

I authorize the release of directory information about the student as permitted by applicable law for school publications and allowable third-party requests. I understand I may request in writing that directory information not be released.

Certifications and Legal Statement

By signing below, I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that this signature page documents my annual review of required school policies and, where indicated, my consents and refusals. I understand that enrollment and participation in school programs are subject to compliance with school policies and applicable laws. I authorize school officials to take reasonable actions in the event of an emergency and release the school and its employees from liability for actions taken in good faith to provide emergency medical care when necessary and after reasonable attempts to contact me have failed.

I understand that this form does not create any contractual right to continued enrollment and that the school retains the right to modify policies and practices as permitted by law. I further understand that any false statements may subject the student to disciplinary action and that I may be responsible for costs resulting from unreported health conditions or treatment.

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