Hazel Wolf K-8 PTSA

[Pages:14]Hazel Wolf K-8 PTSA

New School Year Forms (Electronic Version)

Instructions: The forms you need to complete are included in this packet and have been setup so you can complete it electronically. They are divided into mandatory forms (pages 3-8), optional forms (pages 9-14), and informational documents. Please return the Emergency Contact form ASAP and all others by September 30th.

1. Use Adobe Acrobat Reader to fill in the forms (Mac users: Preview doesn't work well.) 2. Fill in the fields on page 2 and the forms will auto-populate. 3. NOTE: You will still need to review each form as there are specific questions that need to be

answered. 4. Then you can either:

a. Sign forms electronically and email them to startofschooldoc2019-20@; or b. Print, sign, scan and email the forms to startofschooldoc2019-20@; or c. Print, sign and have your child return the forms to the school's front office.

NOTE: ? All forms can be found on the district's website for download. ? Volunteer forms are on-line on the district's Volunteer page.

Ready to start? Skip to page 2

Translated Forms Translated forms can be found by clicking on the specific link below (for other languages, click here).

English 504-2 Survey to Identify Disabled Students

Emergency Information and Student Release

FERPA Preschool, Elementary, K-8, Middle School

Somali TIRA-KOOBKA LAGU CADEEYNAAYO ARDAYDA CUURYAANKA AH

ARJIGA SIDII LAGUULA SOO XIRIIRI LAHAA HADII XAALAD KHATAR AHI DHACDO IYO DADKA KALEE ILMAHA LAGU DARI KARO HADII LAGU WAAYO FOOMKA OGEYSIINTA XAQU YEELASHADA XUQOOQDA WAXBARASHADA QOOSKA iyo QODOBKA SHARCIGA DOWLADA ee GAARKA ah iyo INAAD FARAHA KA QAADO

Spanish Questionario Para Identificar Estudiantes Incapacitados Forma De Informacion Estudiantil De Emergencia Y Autorizacion

Notificaci?n De Sus Derechos Bajo La Ley De Derechos Familiares Educativos Y De Privacidad (Ferpa) Y La Forma De Optar No Participar

Amharic ()

()

(FERPA) opt-out form

Version 3 ? 9/23/2019

Child Information Child First Name Child Last Name Child First and Last Birth Date Student ID Grade Bus number Address City State Zip Code Child Phone Today's Date

Primary Parent or Guardian (PPG) Information PPG Name PPG Home Phone PPG Cell Phone PPG Work Phone PPG Email Address

Second Parent or Guardian (SPG) Information SPG Name SPG Home Phone SPG Cell Phone SPG Work Phone SPG Email Address

Emergency Contact (EC) Information EC Name Relation to Student EC Home Phone EC Cell Phone EC Work Phone

Version 1 ? 9/10/2019

Mandatory Forms ? Emergency Information and Student Release Form Return this form ASAP to help ensure the safety of all students. Please list contact information for persons who will be authorized to pick-up your student if you are not available. ? Parent/Guardian Authorization for Day Field Trip Remember that a signed fieldtrip form is required before any student can participate in a walking fieldtrip. The walking fieldtrip form should be returned as soon as possible. ? Seattle Public Schools (SPS) Notification Of Rights Under the Family Educational Rights And Privacy Act (FERPA) and Opt-Out Form

Version 1 ? 9/10/2019

SEATTLE PUBLIC SCHOOLS

EMERGENCY INFORMATION AND STUDENT RELEASE FORM

SCHOOL__H_a_z_el_W__o_lf_K_8_________________________________________________________________________

Student's Last Name_______________________________ First Name _________________________________ Address_________________________________________ Phone ______________ Bus#________ Grade_____

Name of sibling(s) enrolled at same school _________________________________________________________

Parent/Guardian Name

Home Phone

Work Phone

Cell Phone

Email Address

Parent/Guardian Name

Home Phone

Work Phone

Cell Phone

Email Address

Emergency Contact Name

Relationship

Home Phone Work Phone

Cell Phone

GUARDIANS/NEIGHBORS TO WHOM STUDENT CAN BE RELEASED IN AN EMERGENCY: (Please designate those authorized to pick up your child, keeping in mind the geographical location of the school your child attends.)

Name

Relationship

Home Phone Work Phone

Cell Phone

Name

Relationship

Home Phone Work Phone

Cell Phone

Name

Relationship

Home Phone Work Phone

Cell Phone

Please provide contact information for a friend or family member, who lives out of state, who can be contacted in the event local telephone service is Interrupted____________________________________________________

MEDICATION OR CONDITIONS THAT REQUIRE ATTENTION IF A CHILD NEEDS OVERNIGHT CARE AT THE SCHOOL ARE AS FOLLOWS: __________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________ (Provide 72 hours of the essential medication and complete required "Medication Authorization" form.)

EMERGENCY MEDICAL RELEASE: In the event of a severe emergency or natural disaster such as an earthquake, it is recognized that I may not be able to be reached. Should such an incident occur, I authorize the Seattle School District to refer my child _______________________________as appropriate for any necessary medical treatment. It is my intent and understanding that this medical release be used only in a case of extreme emergency when attempts to reach me have failed.

PARENT/GUARDIAN SIGNATURE_____________________________________________________________ Date Signed

Revised 2/6/13

Seattle Public Schools

Parent/Guardian Authorization for Day Field Trip

TO BE COMPLETED BY THE SCHOOL

Directions: SPS Staff:

1) Use one form per trip. 2) Complete the School Portion of form on page 1. 3) Duplicate one form per student. 4) Send a copy home for parent and student signatures. 5) During the field trip, the signed, original form must be carried by the lead chaperone

and a photocopy must be left on file in the school office.

Students:

1) Complete the "Student Agreement" on page 1.

Parent / legal guardian, if student is under 18 years of age, or student, if at least 18 years old:

1) Complete the "Authorization & Acknowledgement of Risks" section on page 2. 2) Complete the "Medical Authorization" section on page 2.

School Name: Hazel Wolf K8

Student Name:

Date(s) of Trip:

TDA

Destination:

Areas near and around school Property

Purpose(s):

Walking fieldtrip

List of Activities:

TBD

Supervision: (Check One)

Students will be directly supervised by adult chaperones on this trip at all times. Students will be directly supervised by adult chaperones on this trip with the following exceptions:

Mode of Transportation: (Check all that apply.)

s walking

school bus

_________________

public transit

Other

Students will leave from: _H_a_ze_l_W__o_lf_K_8_______________________________ at _T_B_D_________________.

(where)

(time)

Students will return to: _H_a_ze_l_W__o_lf_K_8_________________________________at about _T_B_D____________.

(where)

(time)

Chaperone(s) in Charge:

C__la_s_s_ro_o_m__te_a_c_h_e_rs_a_n_d_v_o_l_un_t_e_e_rs__________________________________________________

Chaperone/Student Ratio: _TB__D_______________________ (max. ratio for K-5, 10:1; max. ratio for Grades 5+, 15:1)

STUDENT AGREEMENT

While participating in this field trip, I understand I will be a representative of SPS and my school community. I understand that appropriate standards must be observed, and I will accept responsibility for maintaining good conduct and abide by school based rules and the Basic Rules of Seattle Public Schools ? Code of Prohibited Conduct.

__________________________________________

Student Signature

_______________________

Date

TO BE COMPLETED BY THE STUDENT

TO BE COMPLETED BY THE PARENT/GUARDIAN OR STUDENT

AUTHORIZATION AND ACKNOWLEDGMENT OF RISKS

I understand that my/my child's participation in this field trip is voluntary and may expose me/my child to some risk(s). I have read and understand the description of the field trip (on page 1 of this form) and authorize myself/my child to participate in the planned components of the field trip.

I assume full responsibility for any risk of personal or property damages arising out of or related to my/my child's participation in this field trip, including any acts of negligence or otherwise from the moment that my student is under Seattle Public Schools (SPS) supervision and throughout the duration of the trip. I further agree to indemnify and to hold harmless SPS and any of the individuals and other organizations associated with SPS in this field trip from any claim or liability arising out of my/my child's participation in this field trip.

I also understand that participation in the field trip will involve activities off of school property; therefore, neither the Seattle Public Schools, nor its employees nor volunteers, will have any responsibility for the condition and use of any non-school property.

I understand that SPS is not responsible for my/my child's supervision during such periods of time when I/my child may be absent from a SPS supervised activity. Such occasions are noted in the "Supervision" section on page 1 of this agreement.

I state that I have/my child has read and agree(s) to abide by the terms and conditions set forth in the SPS Student Rights & Responsibilities, and to abide by all decisions made by teachers, staff, and those in authority. I agree that SPS has the right to enforce these rules, standards, and instructions. I agree that my/my child's participation in this field trip may at any time be terminated by SPS in the light of my/my child's failure to follow these regulations, or for any reason which SPS may deem to be in the best interest of a student group, and that I/my child may be sent home at my own expense with no refund as a result. In addition, chaperones may alter trip activities to ensure individual and/or group safety.

MEDICAL AUTHORIZATION

I certify that I am/my child is in good physical and mental health and I have/my child has no special medical or physical conditions which would impede participation in this field trip.

I agree to disclose to SPS any medications and/or prescriptions which I/my child shall or should take at any time during the duration of the field trip.

In the event of serious illness or injury to my child/ward, I expressly consent by my signature to the administration of emergency medical care, if in the opinion of attending medical personnel, such action is advisable. Further, I authorize the chaperones listed to act on my behalf as parent/guardian of my child/ward while participating in the above described trip including the admittance to and release from a medical facility.

My child DOES NOT require medication during this trip.

My child DOES require medication during this authorized trip.

If you checked yes, please describe in the space below the type of medication and the required administration of this medication. If medication is taken on an as-needed basis, specify the symptoms or conditions when medication is to be taken and the time at which it may be given again.

If the applicant is at least 18 years of age, the following statement must be read and signed by the student: I certify that I am at least 18 years of age, that I have read and that I understand the above Agreement, and that I accept and will be bound by its terms and conditions.

________________________________

Student Signature

Date

If the applicant is under 18 years of age, the following statement must be read and signed by the student's parent or legal guardian:

I certify that I am the parent and legal guardian of the applicant, that I have read and that I understand the above Agreement, and that I accept and will be bound by its terms and conditions on my own behalf and on behalf of the student.

I give permission for: __________________________________________ to participate in all aspects of this trip.

(student

__________________________________

Parent/Guardian Signature

Date

The student, if at least 18 years of age, or the parent/legal guardian must complete the information below:

Print First and Last Name: _________________________________________________________________________

Address: ______________________________________________________________________________________

Telephone: (Cell) _____________________(Home)_______________________(Work) ________________________

Emergency Contact's First and Last Name: ___________________________________________________________

Relationship to Student: ___________________________________________________________________________

Emergency Contact's Telephone #s: _________________________________________________________________

FERPA PreK-8 SEATTLE PUBLIC SCHOOLS (SPS) NOTIFICATION OF RIGHTS UNDER THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) and OPT-OUT FORM Under the Family Educational Rights and Privacy Act (FERPA), parents/guardians of students under age 18, and students over 18 years of age ("eligible students") have certain rights with respect to student "education records." If the student is 18 years old, even if living with the parent/guardian, the student has all the rights under this Act. These rights are: (1) The right to inspect and review their education records within 45 days of the day SPS receives a written request.

(2) The right to request the amendment of an education record for a student that the parent or eligible student believes is inaccurate, misleading, or is in violation of the student's right to privacy. If SPS decides not to amend the record, SPS will notify the parent/guardian or eligible student of the decision and advise them of their right to a hearing regarding the request for amendment. Additional information regarding the hearing procedures will be provided to the parent/guardian or eligible student when notified of the right to a hearing.

(3) The right to provide written consent before the school discloses personally identifiable information contained in the education records of a student, except to the extent that FERPA authorizes disclosure without consent. One exception that permits disclosure without consent is disclosure to school officials with legitimate educational interests. A "school official" is a person employed by SPS as an administrator, supervisor, instructor, or support staff member (including health or medical staff and law enforcement unit personnel). A "school official" also may include a volunteer or contractor outside of the school who performs an institutional service or function for which the school would otherwise use its own employees and who is under the direct control of the school with respect to the use and maintenance of personally identifiable information from education records, such as an attorney, auditor, medical consultant, or therapist, a parent or student volunteering to serve on an official committee, such as a disciplinary or grievance committee; or a parent, student, or other volunteer assisting another school official in performing his or her tasks. A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility. Upon request, SPS discloses education records without consent to officials of another school where a student seeks to enroll.

(4) The right to file a complaint with the U.S. Department of Education concerning alleged failures by SPS to comply with the requirements of FERPA. Written complaints should be directed to Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Avenue S.W., Washington, DC 20202.

Directory Information: Under FERPA, SPS may release "directory" information to anyone, including but not limited to parentteacher organizations, the media, colleges and universities, the military, youth groups, and scholarship grantors, unless you notify SPS in writing that you do not want the information released. The following information is considered directory information: parent/guardian and student name, home address, home telephone number, home email address, student photograph, student date of birth, dates of enrollment, grade level, enrollment status, degree or award received, major field of study, participation in officially recognized activities and sports teams, height and weight of athletes, most recent school or program attended, and other information that would not generally be considered harmful or an invasion of privacy if disclosed.

Release of Directory Information for Students in Grades Pre-Kindergarten to Eight (Pre-K to 8): As a parent/guardian of a prekindergarten student, an elementary student, or a middle school student you have the right to choose between two (2) options on whether directory information concerning your student is released or not. Please check one box below and return this form to the school your student attends no later than October 1, a new form may be submitted in a given school year to change your option status for that year. If the parent/guardian does not check one of the boxes or does not return this form, SPS considers the lack of response as consent for box A. A new form may be submitted in a given school year to change your option status for that year.

Revised July, 2019

FERPA PreK-8

For students in grades Pre-Kindergarten through Eight (Pre-K to 8):

Please select only one box:

A. I consent to the release of the above directory information about the student named below.

OR B. I do NOT consent to the release of the above directory information about the student named below, except as

authorized by law.

The following selections only need to be made if you selected Option B. If you selected Option B ? No Release of Information, your child's information will not be included in the following unless you complete the section below. If you would like your child's information shared in any of the below places, please indicate your consent below by selecting the appropriate option.

School Directory and Classroom Roster Is made available to our families, staff and PTSA. YES, Include our information (phone, address, email)

Photo/Video Student photographs and video may be posted on the school and district external website, social media and district printed publications. No names will be posted. YES, my student's photograph and video can be posted on the district channels.

Yearbook/Class Photo Release YES, I give my consent for my student's photograph and name to be included in the yearbook and class photo

Print Student's Name

Date of Birth

Student's school ID number

Print Signer's Name

Parent/Guardian/Eligible Student's Signature

Date

Notice of Right to File a Public Records Request: Pursuant to RCW 28A.320.160, school districts are required to notify parents/guardians that they have the right, under the Washington Public Records Act (RCW 42.56), to request the public records regarding school employee discipline. To file a public records request with SPS, send a written request, in writing, to: Office of the General Counsel: Attn: Public Records Request; SPS: MS 32151; PO Box 34165: Seattle, WA 98124

PLEASE RETURN THIS FORM DIRECTLY TO THE STUDENT'S SCHOOL EITHER IN PERSON OR BY U.S. MAIL. If you have more than one student, you must return a separate form for each student to each student's school. This form will be retained in your student's folder at his or her school.

Revised July, 2019

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