Student Back-to-School Forms

STUDENT BACK-TO-SCHOOL FORMS

Student Information

Student Name:

Date of Birth:    Student ID:

Primary Phone:    Email:

Parent / Guardian Information

Relationship:    Phone:    Email:

Relationship:    Phone:    Email:

Emergency Contacts & Transportation

Emergency Contact 1:    Relationship:    Phone:

Emergency Contact 2:    Relationship:    Phone:

Student may be released to the following additional authorized adults (names and phone numbers):

Health & Medical Information

Current Medications at School (name, dosage, schedule):

Permission for school staff or contracted health professionals to administer emergency first aid or to seek emergency medical treatment if parent/guardian cannot be reached: I authorize emergency treatment as necessary for the health and safety of my child.

Permission for school to administer non-prescription medications (e.g., acetaminophen, antacid) per school protocol: I authorize over-the-counter medications as needed according to school guidelines.

Consent & Permissions

Field Trip Participation: I permit my child to participate in local and off-site field trips supervised by school personnel. I understand that specific trip itineraries and any additional fees will be communicated in advance, and that emergency medical treatment authorization extends to such events.

Photo / Media Release: I grant permission for my child's image, voice, and work to be used in school publications, promotional materials, and classroom displays. I understand no financial compensation will be provided and may revoke this authorization in writing at any time.

Directory Information Release: I consent to the release of directory information (name, grade, school phone) for school-authorized purposes. I understand I may withhold consent by indicating the alternative below.

Withhold directory information: Do not release any directory information for my child.

Transportation / Bus Permission: I authorize my child to ride the school bus and understand that bus rules and district policies apply. I accept responsibility for communicating pick-up and drop-off arrangements to the school.

Technology & Acceptable Use

Internet, network, and device use is granted under the school's Acceptable Use Policy. I acknowledge that inappropriate use may result in disciplinary action, financial liability for damages, and loss of access privileges.

Student device assignment and responsibility for care and return of equipment: I accept responsibility for the care of any school-issued device and agree to the conditions for use, including potential repair/replacement cost if damaged through negligence.

Policies Acknowledgement

By checking the boxes below, I acknowledge I have received and read the school policies referenced, including the Student Code of Conduct, Attendance Policy, and Health & Safety protocols. I understand my responsibilities and agree to cooperate with school staff in enforcement of these policies.

I acknowledge receipt and acceptance of policies:

Special Education / Services (optional)

If your child receives special educational services (IEP, 504, counseling), please indicate and provide relevant contact or case manager information below so accommodations and services can be coordinated.

Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information, or intentionally omitting material facts, may subject the student to disciplinary action and may affect eligibility for services. I agree to promptly notify the school of any changes to this information.

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