Student Initial Consent Form

STUDENT INITIAL CONSENT FORM

Student Information

Parent / Guardian Information (If student is under 18)

Emergency and Medical Information

Initial Consents (Initial each applicable line)

Emergency Medical Treatment: I authorize school personnel and its agents to obtain or provide emergency medical care for the student if I cannot be reached. This authorization includes transportation to a medical facility and consent to treatment deemed necessary by licensed medical personnel. Initials:

Administration of Medication: I permit school staff to administer medication to the student in accordance with written instructions from a prescribing clinician and to retain a record of such administration. I agree to provide medication in its original labeled container and updated instructions when necessary. Initials:

Field Trips and Transportation: I consent to the student’s participation in routine on-campus activities and off-campus instructional activities including transportation provided by the institution or its authorized carriers. I understand that specific notices may be provided in advance for certain trips. Initials:

Release of Educational Records: I authorize the release of the student’s educational records, including disciplinary and academic records, to authorized school officials and contracted service providers where required for educational programming, compliance, or health and safety. This authorization is limited to education-related purposes consistent with applicable law. Initials:

Media and Photograph Release: I grant permission for photographs, audio, and video recordings of the student to be used for educational, informational, or promotional purposes by the school. I understand such materials may appear in printed or electronic media and will not be used for resale. Initials:

Technology and Acceptable Use: I agree that the student will abide by the institution’s acceptable use policies for computers and networks. I consent to limited monitoring of student activity on school devices and networks for safety and compliance purposes. Initials:

Limited Data Sharing: I permit limited sharing of student data (e.g., assessments, attendance) with third-party partners where required for instruction or student services. The school will take reasonable steps to protect confidential information and will share only information necessary for the authorized purpose. Initials:

Handbook and Policy Acknowledgment: I acknowledge receipt of the student handbook, code of conduct, and related policies, and agree that the student and I will adhere to those policies while enrolled. I understand disciplinary procedures and the school’s expectation for behavior and attendance. Initials:

Restrictions, Conditions, or Special Instructions

Certification and Revocation

By signing below I certify that I am the student if 18 years of age or older, or the parent/guardian of the student if the student is under 18. I have read and understand each consent initialed above. I understand that I may revoke any consent provided herein by delivering written notice to the school; however, revocation will not affect actions taken in reasonable reliance on the consent prior to receipt of the revocation. I further acknowledge that the school will exercise reasonable care in obtaining medical treatment but assumes no liability for treatment decisions made by medical professionals.

I affirm that the information provided on this form is true and correct to the best of my knowledge. I authorize the school to contact the individuals listed for emergency purposes and to follow the instructions provided in this form in order to safeguard the student’s health and well-being.

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