SCMS COMPILED PERMISSIONS FORM

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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. 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 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

4 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

5 SCOTT CITY MIDDLE SCHOOL 809 W. 9th SCOTT CITY, KANSAS PHIONE: (620) FAX: (620) ACKNOWLEDGEMENT OF RISK STUDENT I realize that a risk of being injured exists in all activities. I realize that the risk may be severe, including risk of fractures, brain injuries, paralysis, or even death. Knowing these facts, I choose to participate in Scott County Public School s athletic program. I also acknowledge that the catastrophic insurance coverage provided by USD 466 has been explained to me. : Signed PARENT I realize that a risk of my child being injured exists in any sports program offered by Scott County Public Schools. I realize the risk of injury may be severe, including the risk of fractures, brain injuries, paralysis, or even death. Nonetheless, I consent to allow (student s name) to participate in Scott County Public School s athletic program(s). I also acknowledge that the catastrophic insurance coverage provided by USD 466 has been explained to him/her. Signed

6 SCOTT COUNTY - USD 466 SUBSTANCE ABUSE POLICY CONSENT FORM Policy Statement The Scott County USD 466 Board of Education, in an effort to protect the health and safety of its student athletes/scholars/participants, regardless of age, from illegal and/or performance-enhancing drug/alcohol use and abuse or injuries resulting from the use of drugs/alcohol, thereby setting an example for all other students of the Scott County USD 466 School District has adopted the Substance Abuse Policy for drug/alcohol testing of students. General Authorization Form I have read and fully understand the Scott County USD 466 Substance Abuse Policy. I understand fully that my safety and the safety of my classmates and teammates depends upon my conduct as an individual. I hereby agree to accept and abide by the standards, rules, and regulations set forth by Scott County USD 466 and the teachers, coaches, and/or sponsors for the extracurricular and/or co-curricular activities in which I participate. I also authorize Scott County USD 466 to conduct a urine and/or saliva and/or Breathalyzer on specimens provided by the student to test for drugs and/or alcohol use. The student also authorizes the release of information concerning the results of such a test to Scott County USD 466 and to said parent(s) and/or guardian. I do not agree to accept and abide by the standards, rules, and regulations set forth by Scott County USD 466 Substance Abuse Policy. I understand that my son/daughter will not be allowed to participate in any extracurricular activities or any other school-sponsored activity for the entire school year. Student Signature Printed Name Parent/Guardian Signature Grade Address City State Zip Phone All students wanting to participate in extracurricular activities must sign the Substance Abuse Policy Consent Form, agree to abide by the standards, rules, and regulations set forth in the Scott County USD 466 Substance Abuse Policy, and return it to the school office in which enrolled by the first day of practice and/or before participating in any meetings, practices, performances, and/or competitions, whichever comes first. --Revised 7/18/2005 Committee Revised and Recommended & Approved by BOE 10/17/07 &

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9 Scott City Middle School 809 W 9 th 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. A student s directory information includes, but is not limited to, a student s name, date of birth, honors and awards, pictures, and dates of attendance. Please sign the portion below that indicates your choice, if you do or do not want your child s directory information to be released for publication. 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 such as newspaper, district website, etc. and has the child s best interest in mind. Student Name Parent Signature NO, I request that Scott City Middle School NOT release my student s directory information. I also understand that this prohibits SCMS from publicizing my child s honors, awards, and activities. Student Name Parent Signature

10 EZSchoolMsg In an effort to improve our school to home communications we have implemented EZSchool Messaging. Each Parent now has several options to choose from to receive information from school (i.e. phone call, messages, text messages). First, mark a preferred type of contact then you can choose additional ways. Contact information will be collected from completed student information forms. Please fill out and return this form to the office ASAP. Please call the school office if you have any questions. Student Name: Parent 1 Name: Preferred Contact Type (Please choose 1 type and location under that type) Home Work Text Message Cell Phone Home Phone Work Phone Phone Call Cell Phone Home Phone Work Phone Additional Contact Types (Choose as many of these as you want) Home Phone Allow text messages Allow Phone Call Cell Phone Allow text messages Allow Phone Call Work Phone Allow text messages Allow Phone Call Home Allow messages Work Allow messages Parent 2 Name: Preferred Contact Type (Please choose 1 type and location under that type) Home Work Text Message Cell Phone Home Phone Work Phone Phone Call Cell Phone Home Phone Work Phone Additional Contact Types (Choose as many of these as you want) Home Phone Allow text messages Allow Phone Call Cell Phone Allow text messages Allow Phone Call Work Phone Allow text messages Allow Phone Call Home Allow messages Work Allow messages

11 809 West 9 th Scott City, Kansas (620) Fax (620) Health & Wellness Permission Form The State Board of Education passed an opt-in policy for all students taking health in regards to sex education. For a student to take the sex education curriculum at a middle school in the state of Kansas, the parent or guardian must sign a permission form that states that they grant permission for their student to be exposed to the district s local sex education curriculum. Topics that will be taught in the sex education portion of our health class consists of information to prevent the spread of Aids and sexually transmitted diseases. The curriculum aims to provide information, skills, vulnerability and personal impact to prevent the spread of Aids and other sexually transmitted diseases among young people. If you feel that you do not want your student to participate in this portion of the health curriculum, then we will send the curriculum home as a tool for you as parents or guardians to decide what you want to teach your student. At school, your student will be working on alternate assignments related to health education. Thank you for taking time to consider this important decision. I give permission for my student,, to participate in the sex education program at Scott City Middle School. Parent/Guardian Signature Or I do not give permission for my student,, to participate in the sex education program at Scott City Middle School. Parent/Guardian Signature

12 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

13 USD 466 Kindle Circulation Policy th, 7 th & 8 th Grade Students This form must be completed and signed prior to use of the Kindle. The patron must be in good standing with the library. (No history of unpaid fines or lost or damaged books.) Kindles may be checked out for two weeks with no option for renewal. Patrons will be charged a fee of $5/day for overdue Kindles. Do not place other books or materials on the Kindle. The Kindle and case must be returned to the Librarian (in person) in the same condition it was in when checked out. Patrons are responsible for any damage, loss or theft of the Kindle. Replacement costs will be determined by current prices listed on amazon.com Approximate replacement costs: For all components- $ Kindle Only- $79.00 Cover/Case- $30.00 Kindle Agreement: I will not alter any settings, remove or add any items, access the internet, or connect to any network. I understand that I assume complete financial responsibility for the Kindle checked out to me. Student Printed Name Student Signature Parent or Guardian Signature

14 SCMS Enrollment Fees Fill out for SCMS Fees Payment Plan or Express Pay Fee based on individual student's schedule. Student Name Student Name Student Name Grade Grade Grade 5th Grade 6th Grade Curriculum & Instructional Fee $45.00 Curriculum & Instructional Fee $45.00 Agenda Book Fee $6.00 Agenda Book Fee $6.00 Art Fee $5.00 Home Ec $5.00 TOTAL $56.00 Art Class $7.50 TOTAL 7th Grade 8th Grade Curriculum & Instructional Fee $45.00 Curriculum & Instructional Fee $45.00 Agenda Book Fee $6.00 Agenda Book Fee $6.00 Home Ec $7.50 Home Ec $10.00 Art Class $7.50 Art Class $10.00 TOTAL TOTAL PE Uniform Other Fees Due Set $20.00 Lunch Account Shirt Only $8.00 Other: Shorts Only $15.00 TOTAL TOTAL Total Payment Owed Total Payment Received Remaining Balance Office Initial

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