Student BOY Template

Student BOY Template

Student Information

Student Name:

Date of Birth:    Student ID:

Primary Parent / Guardian

Secondary Parent / Guardian (if applicable)

Emergency Contacts (Other Than Parent/Guardian)

Contact 1 Name:   Relationship:

Phone:   Alternate Phone:

Contact 2 Name:   Relationship:

Phone:   Alternate Phone:

Medical & Health Information

Student has a chronic condition or significant medical history requiring school awareness: Yes

I authorize the school nurse or trained personnel to administer non-prescription medications (e.g., acetaminophen, ibuprofen, allergy medication) according to policy and parental direction: Consent

Transportation & Dismissal

Regular Mode of Transportation: Bus Parent/Guardian Pickup Walker Aftercare

Academic & Special Services

Has the student previously received special education services (IEP)? Yes No

Has the student been identified with a 504 plan? Yes No

Permissions & Consents

Media/Photo Release: I authorize the school to photograph or record my child for school publications and non-commercial educational purposes. I consent

Release of Directory Information: I authorize release of directory information (student name, grade, school activities) for school publications and yearbook. I consent

Field Trip Permission: I grant permission for my child to participate in routine off-campus activities and supervised walking trips during the school year. I understand separate consent may be sought for higher-risk activities. I consent

Acknowledgments, Authorizations and Certifications

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that willful falsification of information may result in disciplinary action and/or administrative consequences pursuant to school policy.

I authorize school personnel to obtain emergency medical treatment for my child if I cannot be reached. I agree to be financially responsible for expenses incurred in the course of such treatment. I authorize release of medical records to emergency medical personnel if required for treatment.

I acknowledge that I have received, read, and accept applicable school policies including attendance, conduct, and technology use. I understand that compliance with these policies is a condition of my child's continued enrollment.

If custody or court orders affect this student's care or release, I have provided an official copy to the school office and attest that the copy is current and complete.

Additional Notes

Sign Now