Student Journey Form

STUDENT JOURNEY FORM

Student Information

Date of Birth:    Student ID:

Parent / Guardian Information

Relationship:    Phone:

Emergency & Medical Information

Relationship:    Phone:

I authorize school staff to administer routine first aid and to contact emergency medical services if necessary.

Academic History, Goals & Action Plan

Learning Profile & Accommodations

Learning preferences (check all that apply): Visual Auditory Kinesthetic Other:

Existing plans (check all that apply): IEP 504 Plan ESL / ELL Tutoring Counseling

Data Use, Privacy & Consent

By signing below, I certify that the information provided on this Student Journey Form is accurate to the best of my knowledge. I authorize the school to collect and maintain the educational, health, and support information necessary to implement the academic plan and to share that information with school staff and contracted service providers who have a legitimate educational interest. Information will be used only for educational planning, safety, and compliance with applicable school policies.

I understand that consent for certain services (for example, outside counseling, medical interventions, or specialized assessments) may require additional written consent forms. I understand I may request review or correction of my student's record in writing and that the school will retain records in accordance with its retention policies.

I hereby consent to the collection, use, and sharing of my student's information as described above.

Acknowledgment of Responsibilities

The student (or parent/guardian for students under the age of majority) is responsible for providing accurate background and medical information, for participating in planning meetings, and for cooperating with recommended supports and interventions. The school is responsible for making reasonable efforts to implement the agreed accommodations and for documenting progress toward stated objectives.

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