Student Back to School Paperwork

STUDENT BACK TO SCHOOL PAPERWORK

Student Information

Date of Birth:    Student ID:

School Start Date:

Primary Phone:    Email:

Parent / Guardian Information

Relationship:    Primary Phone:

Secondary Phone:    Email:

Emergency Contacts (Other Than Above)

Relationship:    Phone:

Relationship:    Phone:

Authorized Pick-Up / Transportation

List persons authorized to pick up the student. Include full name and phone number. The school will release the student only to individuals listed below unless otherwise provided in writing.

Transportation preference (check all that apply):
Bus transportation    Walk home    Carpool / Parent pickup

Medical Information & Emergency Authorization

The information provided below will be used to respond to medical situations at school and during school-sponsored activities. Failure to disclose relevant medical information may limit the school's ability to assist the student.

Physician Name:    Phone:

Health Insurance Provider:    Policy Number:

I authorize designated school personnel to administer age-appropriate over-the-counter medications (e.g., acetaminophen, ibuprofen, antacid) in accordance with school protocol when parent/guardian consent is required.

Emergency Treatment Authorization: By signing below, I authorize school employees and representatives to seek emergency medical treatment for my child if I cannot be reached. I authorize medical professionals to perform examinations, administer treatments, and provide transportation to a medical facility as deemed necessary. I agree to assume financial responsibility for any such care and to hold the school and its employees harmless for actions taken in good faith to secure treatment, except where prohibited by law.

Immunization Records

The school requires immunization documentation consistent with applicable law and district policy. Indicate the status below.

Immunization record is on file with the school nurse.    Medical or religious exemption submitted (attach documentation).

Media / Directory / Records Release

Directory information may include student name, grade level, school program, and parent/guardian contact information. Media may include photographs and video of school activities. Indicate consent choices below.

I grant permission for the student to be photographed or recorded for school publications, promotional materials, and classroom use.

I consent to release of directory information to authorized school personnel and organizations for legitimate educational purposes.

Technology Acceptable Use

I have read and agree to the school's technology acceptable use requirements. I understand that violation of technology policies may result in suspension of device or network privileges and possible disciplinary action. The parent/guardian is responsible for charges resulting from unauthorized purchases or damages caused by willful misuse.

I acknowledge and accept the technology acceptable use requirements.

Acknowledgements & Permissions

By signing this form, I acknowledge that I have read the student handbook, attendance and discipline policies, and school safety procedures or have been offered the opportunity to review them. I understand the expectations and will support the school's efforts to maintain a safe and productive learning environment.

Field Trips and Off-Site Activities: I give permission for the student to participate in authorized school-sponsored field trips and off-site educational activities during the school year unless I have indicated otherwise in writing to the principal.

Release of Records to Authorized Parties: I authorize the school to release the student's education records or copies thereof to persons listed on this form for legitimate educational purposes, consistent with applicable law.

Additional Notes

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