SCMS COMPILED PERMISSIONS FORM

Transcripción

1 SCMS COMPILED PERMISSIONS FORM (Please Print) Student s Name Grade FIELD TRIPS: Parent Initial of agreement I hereby give permission for my son/daughter, to be a participant in the Scott City Middle School classroom field trips during the school year. This form shall be effective for all classroom field trips associated with the Scott City Middle School and shall be kept on file in the Scott City Middle School office until the close of the current school year. This form does not include athletic events as the coach will provide permission forms during the particular sport. AGENDA HANDBOOK: Parent Initial of agreement I will read and discuss this agenda handbook with my child before school starts. To improve the child s skill in school, I will check this agenda handbook every day after school. EMERGENCY CONSENT: Parent Initial of agreement If the parent or guardian cannot be contacted, we, the undersigned parents of the child identified above, hereby authorize officials of the above school district to contact directly the physicians of our selection. And we hereby certify that we are the parents of the said minor child and do authorize the physician name to render such treatment as said physician may deem reasonably necessary, in an emergency, for the health of said child without further authorization than here expressed. In the event the physician here name can be contacted or either of us is unavailable to give our express consent at such time with reference to any other physician, we hereby consent and authorize said physicians render such treatment as he may deem reasonably necessary, in what he may consider to be an emergency, for the health of our aforesaid minor child. Expense incurred as a result of emergency ambulance use or treatment by physician will not be borne by the school or school personnel. With the following signature, I also verify that all information on this form is both accurate and current. Parent or Legal Guardian Signature Student Signature

2 SCMS VARIOS FORMULARIOS DE PERMISOS (Letra de molde) Nombre del estudiante Grado Fecha VIAJES: Yo doy permiso para que mi hijo(a), participe en los viajes de Scott City Middle School durante el año escolar. Esta forma deberá ser efectiva para todos los viajes asociados con la Escuela de Scott City Middle School y se mantendrá en los archivos de la oficina de Scott City Middle School hasta el cierre del año escolar. En este formulario no se incluyen los eventos deportivos, el entrenador proveerá formularios de permiso durante el deporte en particular. Ejemplos: clases de Finanzas van de visitas al banco o quinto grado de visita a la biblioteca. EL LIBRO DEL AGENDA: Voy a leer y a discutir el libro del agenda con mi hijo(a) antes de que comience la escuela. Para mejorar la habilidad del niño(a) en la escuela, voy a revisar el libro del agenda todos los días después de la escuela. PERMISO PARA HABLAR CON LA CONSEJERA: En el caso de que su hijo se moleste en la escuela y no quiera hablar con un profesor, me gustaría que él / ella pueda visitar a nuestro consejero, Linn Collins. Si el problema resulta ser más grave, la señora Collins le llamará. La Sra. Collins es un psicólogo de la escuela. CONSENTIMIENTO DE EMERGENCIA: Si el padre o tutor no puede ponerse en contacto con nosotros, los padres firmantes de los niños identificados por encima de la presente autorizo a los funcionarios del distrito escolar de arriba para contactar directamente con los médicos de nuestra selección. Y que la presente certifico que somos los padres de dicho menor y se autoriza el nombre del médico para hacer el tratamiento, como dijo el médico considere razonablemente necesario, en caso de emergencia, para la salud de dicho niño. sin más autorización que aquí expresado. En el caso de que el médico de aquí el nombre puede ser contactado o cualquiera de nosotros no está disponible para dar nuestro consentimiento expreso en el momento en relación con cualquier otro médico, que consiente y autoriza dijo que los médicos hacen este tratamiento que considere razonablemente necesario, en lo que se puede considerar una situación de emergencia, para la salud de nuestro hijo menor de edad mencionado. Gastos incurridos como resultado del uso de ambulancias para emergencias o tratamiento médico no serán asumidos por el personal de la escuela o la escuela. Con la siguiente firma, también comprobar que toda la información en este formulario es precisa y actual. Firma de los Padres/Tutor Fecha Firma de el Estudiante Fecha

3 Scott City Middle School 809 W. 9th St. Scott City, KS (620) The Family Education Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records. FERPA give parents certain rights with respect to their children s education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. School s may disclose directory information such as a student s name, address, telephone number, date and place of birth, honors and awards, pictures, and dates of attendance. If you do not want your child s directory information to be released, then please sign the portion below which indicates that choice. FERPA does allow schools to disclose records, without consent, to certain parties including but not limited to: school officials with legitimate education interest, other schools to which a student is transferring, auditors, to comply with a judicial order or lawfully issued subpoena. For a full list of agencies that can request records, please visit and search for FERPA. YES, I wish to allow for Scott City Middle School to release directory information only about me/my student to agencies that the school deems reputable and has the child s best interest in mind. Student Name Parent Signature NO, I request that Scott City Middle School NOT release my/my student s directory information. Student Name Parent Signature

4 USD #466 Student Network and Internet Access Agreement Parents & Students: The purpose of this agreement is to outline the rules for using the local area network and the Internet at Scott County USD #466. Because of the cost and sensitivity of computer equipment, and the unregulated nature of material found on the Internet, all parents and students must understand the rules for usage. Instructions: Please read the following document and sign at the bottom of this page. We will review this document with each student annually. The use of school computers is a privilege, which may be taken away if the student uses computers, the network, or the Internet improperly or causes damage to computer hardware or software. A. Students will not install unauthorized software or download unauthorized files on school computers. B. The computers are to be used only for schoolwork as directed by the teacher or staff. C. Each student is responsible for good behavior while using technology and/or the network. The same rules that apply with regard to common courtesy and respect for people and property also apply with regard to use of the school computer network and the Internet. Improper use will lead to technology privileges being taken away for the student. D. The student will only use the Internet under the supervision of a teacher or staff member. E. The district has the right to review (or monitor) all activities, correspondences, and material created by students on school computers. F. If this agreement is not signed by the parent and student, student will not be allowed computer access. Use of computers, the network, and/or the Internet by student with unsigned agreement will result in disciplinary actions as determined by the principal. Network and Internet Permission Slip By signing this document, the student and parent indicate that they have read the Network and Internet Access Agreement and agree that the student will abide by the rules stated therein. Students will not be able to use the Internet unless a signed agreement is on file with the school. APPROVAL OF ACCESS TO THE INTERNET: Parent: As the student s parent and/or guardian, I have read and agree to the terms described in the Network and Internet Access Agreement. I give permission for my student to use the computer network and Internet at Scott County USD #466 Schools. Signature of Parent Student: I agree to abide by the rules and regulations set forth in the Network and Internet Access Agreement. Student 9

5 USD #466 STUDENT EMERGENCY INFORMATION AND CONSENT FORM Name Grade Address Allergies or Chronic Illnesses Medication or inhaler use It is necessary for all students that participate in any type of school activities to be covered by some type of health and accident insurance. The school will not carry any type of health or accident insurance on any child. Insurance Company Insurance ID # I am insuring my student under the Security Life Insurance Plan $ Premium In case of an accident, an illness, or an emergency, please notify one of the following: (1) Parent/Guardian Cell Phone Alternate Phone (2) Parent/Guardian Cell Phone Alternate Phone (3) Other emergency contact Cell Phone Alternate Phone I (we) understand that accidents may occur in athletics or other activities even though normal acceptable safty precautions have been taken. My Son/Daughter has my permission to practice and compete in the interscholastic program or other School Sponsored activities. In the event neither parent/guardian is available to give his/her express consent, we here by authorize officials of the above school district to contact any physician, we hereby consent and authorize said physician to render such treatment as he/she may deem reasonably necessary, in what he/she may consider to be an emergency, for the health of said minor child. Parent/Guardian Parent/Guardian NOTE: Expenses incurred as a result of emergency ambulance use, treatment by a physician, or hospital services will not be borne by the school district or school personnel. This sheet along with a current Physical examination form must be on file with the Activity Director at your child s school before participation will be allowed! 3

6 USD #466 INFORMACIÓN DE EMERGENCIA DEL ESTUDIANTE Y CONSENTIMIENTO Nombre Grado Dirección Allergias o Enfermedades Chronicas Medicamentos o uso del inhalador Es necesario que todos los estudiantes que participan en cualquier tipo de actividad de la escuela estén cubiertos por algún tipo de seguro de salud y accidente. La escuela no realizará ningún tipo de seguro de salud o accidente para ningún estudiante. Compañía de Aseguranza # de identificación El Plan de Security Life Insurance Plan que compramos aqui. $ Costo En caso de un accidente, una enfermedad o una emergencia, por favor notifique a uno de los siguientes: (1) Padre/Guardián Celular Teléfono Alternativo (2) Padre/Guardián Celular Teléfono Alternativo (3) Otro contacto de emergencia Celular Teléfono Alternativo Yo entiendo que los accidentes pueden ocurrir en deportes u otras actividades a pesar de que se hayan tomado las precauciones de seguridad normales aceptables. Mi hijo / hija tiene mi permiso para practicar y competir en el programa inter-escolar u otras actividades patrocinadas por la escuela. En el caso de que ninguno de los padres / guardianes están disponibles para dar su consentimiento expreso, por la presente autorizo a los oficiales del distrito escolar 466 de ponerse en contacto con cualquier médico(a), por la presente consiento y autorizo dicho médico(a) para hacer un tratamiento que él / ella considere razonablemente necesario, en lo que él / ella puede considerar que es una emergencia, por la salud de dicho menor. Fecha Padre/Guardián Fecha Padre/Guardián NOTA: Los gastos incurridos como resultado del uso de ambulancia de emergencia, el tratamiento por un médico o servicios de hospital no serán asumidos por el distrito escolar ni el personal de la escuela. Esta forma y la forma del examen físico completada por un médico tienen que estar entregadas al Director de Actividades de la escuela antes de que el/la estudiante puede participar en cualquier actividad. 3

7 (This page to be filled out by Grades PreK-6 th ) UNIFIED SCHOOL DISTRICT #466 Dear Parents/Guardians: The School District does not provide any type of health or accident insurance for injuries incurred by your child at school. REASONS TO PURCHASE THIS COVERAGE: 1. Deductibles and co-pays in your health plan. Many health plans have increased the amount of outof -pocket expenses. 2. No insurance. This plan will provide benefits for medical expenses incurred because of an accident. If you have other insurance, our benefits will be applied to your deductible or co-pay. If you have no other insurance this will become your primary accident plan. To purchase coverage: 1. Print names, addresses and other information clearly. 2. Enclose check or money order (NO CASH) made payable to STUDENT ASSURANCE SERVICES, INC. or Complete the credit card payment form 3. Print Student s name on the face of the check. 4. Detach and retain the summary of coverage, and return the envelope to school within 10 days. Coverage will become effective at 12:01 a.m. following the date the enrollment form and premium are received and dated by the school. 5. All questions regarding the coverage may be directed to Student Assurance Services, Inc., at (651) , or toll free Please sign and return the form below to school, if you already have adequate insurance. ********************************************************************************************* PARENTAL INSURANCE WAIVER School Year Student s Name_School We have adequate insurance to protect our son/daughter in case of an accident. Parent s/guardian s Signature The program is underwritten by Security Life Insurance Company of America located in Minnetonka, Minnesota and administered by Student Assurance Services, Inc. of Stillwater, Minnesota.