Student Encompass Form

STUDENT ENCOMPASS FORM

Student Name:    Date of Birth:    Student ID:

STUDENT INFORMATION

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACTS

Contact 1 Name:    Relation:    Phone:

Contact 2 Name:    Relation:    Phone:

MEDICAL / HEALTH INFORMATION

I authorize school personnel to administer the above listed medication(s) according to directions from a licensed prescriber and in compliance with school policy. If authorization is granted, complete medication_authorization_details.

SPECIAL EDUCATION / ACCOMMODATIONS

Student has an active IEP    Student has a 504 Plan    No IEP or 504 on file

TRANSPORTATION AUTHORIZATION

Student is authorized to ride school bus    Student may walk home    Student will be released to parent/guardian

MEDIA / IMAGE RELEASE

I grant permission for the school to photograph or record my student for educational, promotional, and archival purposes. I understand images may be used in school publications, presentations, and internal communications. I waive any right to compensation for such use. I retain the right to limit usage in writing below.

I CONSENT to media/image use    I DO NOT CONSENT to media/image use

TECHNOLOGY & ACCEPTABLE USE

Students are granted supervised access to district network resources and devices. Misuse of technology is subject to disciplinary action. The student and parent/guardian agree to comply with the Acceptable Use provisions and acknowledge responsibility for damage or intentional misuse.

I have read and agree to the Technology Acceptable Use terms

STUDENT RECORDS / FERPA CONSENT

By default, educational records are protected under applicable privacy laws. I authorize the release of educational records to authorized parties for the purposes specified below.

I CONSENT to release records

FINANCIAL AGREEMENT

Tuition and fees assessed for enrollment are due according to the billing schedule. Failure to meet payment obligations may result in suspension of services or withholding of records. By signing below, the responsible party acknowledges financial responsibility for charges incurred.

I acknowledge and accept responsibility for financial obligations as described above.

ACKNOWLEDGMENTS & CERTIFICATIONS

The undersigned certifies that the information provided is true and complete to the best of their knowledge. The undersigned agrees to notify the school immediately of any changes. The undersigned releases the school and its employees from liability for actions taken in good faith under the authorities granted herein, including emergency medical care, except in cases of willful misconduct or gross negligence.

By signing this form I acknowledge receipt and acceptance of applicable school policies including but not limited to the code of conduct, attendance expectations, and the technology acceptable use policy.

I acknowledge that I have read and understand the foregoing statements and certifications.

Sign Now