sandusky digital learning center registration... · 2020-07-21 · pride tradition excellence...

Pride Tradition Excellence

Sandusky Digital Learning Center 617 Jackson St., Sandusky, OH 44870-2740 419-984-1060 www.scs-k12.net

Welcome to Sandusky Digital Learning Center We are glad you are with us and want to make your child’s registration a quick and easy process. By providing the following required information at time of registration, you will have completed the process for your child’s school enrollment. After securing all of the following documentation, please call 419-984-1060 to schedule an appointment. At the time of registration copies are made for our records and the original is returned to you. NEW LOCATION for SDLC is at 617 Jackson St.

REGISTRATION PACKET

Required Documents ____ Birth Certificate/Passport: Original certificate containing raised seal/original stamp, or official passport. In accordance with Ohio Revised Code 3313.64 and Federal Law, S. 249 (106th): Missing, Exploited, and Runaway Children

Protection Act, you (parent/guardian) are required by law to provide a certified birth certificate and/or passport upon registration.

____ Parent/Guardian Photo ID: Only Drivers License, State ID, or passport will be accepted.

____ Proof of Residency: (Provide one of the following) Photo I.D. of parent/guardian, USPS Change of Address card, utility bill, rental/lease agreement, checking/savings account, credit card statements, insurance bills, or US mail delivered to your home, etc. All documents must show a recent date. If you are living with a friend or relative please provide a written statement with their signature and phone number along with one of the above documents listed in their name.

____ Previous School: (if applicable) Name, address, city, state, zip code, phone/fax of previous school

The Following Documents are Required if Applicable

____ Special Education: MFE/IEP/ETR Legal documents for children needing special services

____ Divorce Decree: In accordance with Ohio law, a complete copy of the decree (signed by Judge) must be provided.

____ Legal Documents: Name change, adoption or custody papers. If a child is NOT living with their biological parent(s), a change of custody must be filed with Erie County Court and a copy of the filed document produced for school record. Legal documents must contain journal entry, date stamp from the court, and judges signature. We can provide information for obtaining these documents.

____ Grandparent Act: Power of Attorney for Grandparents – A free legal document provided by Ohio law for grandparents who are caring for their grandchildren. Please ask us for information if this is something you need.

____ If you are not able to meet the above criteria due to conditions of homelessness, please contact the Assistant Superintendent at 984-1015

Again, welcome to Sandusky Digital Learning Center.

Sandusky High School

2130 Hayes Avenue, Sandusky, Ohio 44870-4740

NEW STUDENT "ITEMS RECEIVED" CHECKLIST

New Student’s Name: ____________________________________________________ Grade: ____

Enrollment Date: ____________________________

Counselor: ____________________________________________________________

SHS Required Forms: Notes:

_____Registration Form (Form 059)

_____Consent for Release of Student Records 7-12 (Form 043A)

_____Student Educational Records Release (Form 024)

_____Health History/Nurse Interview Form (Form 030-3)

_____Emergency Medical Authorization Form (Form 005)

_____Student Authorization Forms Combined (Form 019)

Personal Items Required:

_____Original Birth Certificate/Passport (within 2 weeks)

_____Health/Immunization Records (within 2 weeks)

_____Custody/Legal Documents (if applicable) (within 60 days)

_____Parent/Legal Guardian Photo ID

_____Residential Identification Form (Form 041) (Proof of Residency)

Items from Previous School Required:

_____Attendance Record

_____Signed, Official Transcript

_____Current Transfer Grades

_____Standardized Test Scores

_____Raw OGT Scores

_____End of Course State Test

_____ACT/SAT Scores

_____Psychological Reports (ETR & IEP)

_____Other:______________________________________________________________________

Main Office

419-984-1068

419-984-1069

Fax 419-621-2751

Guidance Office

419-984-1083

Fax 419-624-3349

Attendance Office

419-984-1090

Athletics & Activities

Office

419-984-1075

Fax 419-621-2879

Career & Technical

Department

419-984-1100

Fax 419-621-2893

For departments not listed

please call 419-626-6940

or visit www.scs-k12.net.

Sandusky High School - Registration Form 2130Hayes Avenue, Sandusky, OH 44870-4740

Phone: 419-984-1083 Fax: 419-624-3349 Website: www.scs-k12.net

First Name Middle Name Last Name Date of Birth

________/________/______

Address Apt. Home Phone

______-______-______

Work Phone

_______-________-________

Cell Phone

_______-_______-________

Grade ____

Gender: Male_____ Female_____

Student I.D. (assigned by district)

______________________

Ethnicity/Race Answer both questions (Required by the U.S. Dept. of Education, 72 Fed. Reg. 59267)

1. Ethnicity of child: (please check one) Hispanic/Latino Yes__ No__

2. Race of child: (check all that apply)

American Indian or Alaska Native ____ Asian ____ Black/African American ____

Native Hawaiian/other Pacific Islander____ White/Non-Hispanic____

Place of Birth

City__________________________, State______

Primary language spoken at home:

English_____

Other (specify)_____________________

Has student ever attended Sandusky

City Schools?

Yes_____, last year attended_________.

No______

Previous School Attended, last date attended

________________.

Services Received: Special Education (IEP/MFE) _________

ESL Services________ Gifted________ 504 Plan________

Previous School Address/City/State/Zip Previous School

Phone______________________Fax_________________________

Biological Parent Information

Mother Last Name____________________________ First Name__________________________ Maiden Name_____________________

Address, if different from above_________________________________ City____________________ State___________ Zip_________

Father Last Name______________________________ First Name______________________________

Address, if different from above_________________________________ City____________________ State__________ Zip _________

If child lives with Legal Guardian/Foster Parent/Other, please provide the following information.

Last Name_________________________________ First_______________________________

(Legal Guardian/Foster Parent/Other must reside at the above address listed for child.)

Custody Legal Guardian______ Foster Parent______ Grandparent Act______ Other_____________________________________

Proof of Age Proof of Address

____Birth Certificate ____90 Day Waiver

____Baptismal Certificate ____Lease

____Passport ____Mortgage Statement

____Other, specify_____________________________ ____Bill (i.e.: Utility /Tax) ____Other, specify________________________

To the best of my knowledge, the above information is correct and I am aware will be filed with my child’s school records.

Parent/Guardian Signature____________________________________________________________ Date______________________

If child is NOT living with both Natural Parents, is there a temporary or permanent custody order/decree allocating parental rights and

responsibilities? Yes______ No______ If yes, you must provide a certified/journal entry stamped copy of that order and any future

changes or modifications.

Residential Information, Child lives with: Biological/Adoptive Parents_____ Mother only_____ Father only_____ Grandpar -

ents_____

Mother/Stepfather_____ Father/Stepmother_____ Foster Parents_____ Other________________________________________________

District of Residence_______________________________________________________________________________________________

Start Date (office use only)

_______________

Fo

rm 0

59

13

12

11

-20

16

COUNSELOR'S INTERVIEW ____ Homeless: Yes/No Situation:_____________________________________________________ ____ Currently Suspended:___________________________________________________________ ____ Expelled:_____________________________________________________________________ ____ Contact made to Former School? Yes/No OGT Tests: Students entering as 10th graders after March. List Dates and Scores (include all scores and attempts).

R. ____________________ M. ____________________ W. ____________________

SCI. ____________________ SOC ST. ____________________

ADMISSION DATE: ____________________ COURSE REQUESTS: Course Number Course Title 1 ________ ______________________________

2 ________ ______________________________

3 ________ ______________________________

4 ________ ______________________________

5 ________ ______________________________

6 ________ ______________________________

7 ________ ______________________________

8 ________ ______________________________

9 ________ ______________________________

10 ________ ______________________________

11 ________ ______________________________

12 ________ ______________________________

13 ________ ______________________________

14 ________ ______________________________

NOTES:_________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

EMIS#______________________________ Interview completed by: ______________________________ Today's Date:______________________________

Sandusky City Schools 407 Decatur Street, Sandusky, Ohio 44870-2442

419-626-6940

RESIDENTIAL IDENTIFICATION FORM

Parent/Guardian/Student: This form is intended to address the McKinney-Vento Act 42 U.S.C. 11435, and must be completed for each child. The information you provide is confidential. Your child will not be discriminated against based upon the information provided. Please check one option below regarding the child’s current housing in order to help determine services the child may be eligible to receive.

CHECK ONE

PLEASE CHECK ONE OF THE BELOW

Doubled-Up: With another family or other person because of loss of housing or economic hardship.

Shelter: Emergency or transitional shelter

Hotel/Motel: Living in what is NOT an emergency or transitional shelter and involves payment.

Other Temporary Living Situation: Trailer park, campground, car, park, public places, abandoned building, street, or any other inadequate living space.

Permanent Housing: Student who is living in a fixed, regular, and adequate housing situation.

If the student is NOT living in permanent housing, also indicate if the below applies:

Unaccompanied Youth: Youth who is not in the physical custody of a parent or guardian.

_________________________ ___________________________ ________________ Parent/Guardian (Print) Parent/Guardian Signature Date

Note: The answer you give above will help determine what services you or your child may be eligible to receive under the McKinney-Vento Act. Students who are protected under the Act are entitled to immediate enrollment in school even if they do not have the documents needed, such as proof or residency, school records, immunization records, or birth certificates.

Form 041 1312 Revised 11-14-2011

This page intentionally left blank.

Sandusky City Schools 407 Decatur Street Sandusky, OH 44870-2442 419-626-6940

CONSENT FOR RELEASE OF STUDENT RECORDS 7-12

This signed form authorizes the release of student records to Sandusky City Schools and allows authorized school personnel and indicated others, to discuss records and progress. Student’s Name__________________________________________ Date of Birth_______________ District of Residence_____________________________________________________ Grade_____ Last Date of Attendance___________________ Last school year of attendance________-________ ____ Student is Open Enrolled in Sandusky City Schools (IRN 044743) ____ Student moved into Sandusky City School district on __________________________________ Send to:

Please release the following information: Enrollment Information: X All personally identifiable data As of (date)________________ X Attendance Record the student: X Transcript of grades ____ has Open Enrolled X Standardized test scores ____ is Court Placed X Health/Immunization record ____ moved to Sandusky City Schools X Psychological Reports (IEP, MFE, Parent consent, etc.) ____ other reason:_______________ X Birth Certificate Address:_______________________ X SSID Number (Ohio school systems only) ______________________________ X Other______________________________________ X Authorizes school personnel to discuss student’s records and progress X Authorizes the following additional people to discuss student’s records and progress: _________

________________________________________________________________________________

________________________________________________________________________________ Student Signature__________________________________________________________________ or Parent/Guardian Signature___________________________________________________________ (This signature is required of all students under 18 years of age.)

Date_________________________ Form #043A 1312 Revised 07-20-20

Sandusky Digital Learning Center 617 Jackson St Sandusky OH 44870-2740 Phone 419-984-1060 Fax: 419-502-2305

Sandusky Middle School 2130B Hayes Avenue Sandusky OH 44870-4740 Phone 419-984-1180 Fax: 419-621-2849

Sandusky High School c/o Guidance Department 2130 Hayes Avenue Sandusky OH 44870-4740 Phone 419-984-1083 Fax: 419-624-3349

Sandusky City Schools 407 Decatur Street, Sandusky, Ohio 44870-2442

419-626-6940

STUDENT EDUCATIONAL RECORDS RELEASE This form provides the parent/legal guardian or eligible student the ability to select other adults to view a student’s records. For example: Grandparents or step-parents that are not legal guardians during a Parent/Teacher Conference. The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives 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. Students to whom the rights have transferred are "eligible students."

Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies.

Schools must have written permission from the parent or eligible student in order to release any information from a student's education record to family members or other approved adult(s).

Parent/Legal Guardian or Eligible Student if you want your child’s (your) education records shared, please complete the following and return it to the school your child attends.

(PLEASE PRINT)

Name of Student: ____________________________________________

School: ____________________________________________________ Date: ______________________________

I give consent to allow my child’s (my) education records shared with the following: (Please Print)

Name_______________________________________________________ Relationship_________________________






Parent/Legal Guardian or Eligible Student Signature:____________________________________________________

Date: ______________________________

This form is valid for one school year only, unless rescinded by the above Parent/Legal Guardian or Eligible Student. To rescind, please send a letter stating your request to the building principal. FERPA allows schools to disclose records, without consent, to the following parties or under the following conditions (34 CFR § 99.31): School officials with legitimate educational interest; Other schools to which a student is transferring; Specified officials for audit or evaluation purposes; Appropriate parties in connection with financial aid to a student; Organizations conducting certain studies for or on behalf of the school; Accrediting organizations; To comply with a judicial order or lawfully issued subpoena; Appropriate officials in cases of health and safety emergencies; and State and local authorities, within a juvenile justice system, pursuant to specific State law. Schools may disclose, without consent, "directory" information such as a student's name, address, telephone number, date and place of birth, honors and awards, and dates of attendance. However, schools must tell parents and eligible students about directory information and allow parents and eligible students a reasonable amount of time to request that the school not disclose directory information about them. Schools must notify parents and eligible students annually of their rights under FERPA. See Sandusky City Schools form 020.

Form 024 1200 10-2010

Sandusky City Schools 407 Decatur Street Sandusky, Ohio 447870 419.626.6940

HEALTH HISTORY/NURSE INTERVIEW FORM

To be completed by parent or guardian.

Please print or type

Student’s Name___________________________________________________________ Date _____________________________________ Last First Middle

School______________________________________________________ Grade______ Sport ______________________________________

1. Has your child ever sustained an injury which prevented him/her from playing sports for more than one day? If so, please check all areas.

____Concussion/Loss of Consciousness ____Back Injury ____Pulled Muscle, Ligament, Sprain

____Other Head Trauma ____Broken Bone/Fracture ____Frequent Knee Pain

____Serious Neck Trauma ____Dislocated (out of place) Joint ____Heat Exhaustion

____Arm/Finger Numbness or Weakness ____Deep Muscle Bruise ____Other _________________________________

If you checked any of the above, please explain and include date of injury: ______________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

2. Does your child have a history of:

____Asthma/Wheezing ____Fainting ____Hernia/Rupture

____Arthritis ____Seizures ____Skin Disease/Boils/Rash

____Heart Murmur ____Hepatitis/Yellow Jaundice ____Operations/Surgery

____Chest Pain/Irregular Heart Beat ____Mononucleosis ____Mental/Emotional Problems

____Rheumatic Fever ____Anemia ____Hyperactivity/Attention Deficit Disorder

____High Blood Pressure ____Blood Disorder ____Hypoglycemia/Low Blood Sugar

____Diabetes ____Sickle Cell Disease ____Other _________________________________

If you checked any of the above, please explain: ___________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

3. Is there any family history of medically unexplained or cardiac caused sudden death under age 50? ____Yes ____No

If yes, please explain: ________________________________________________________________________________________________

_________________________________________________________________________________________________________________

4. If your child is taking medication on a regular basis, please list medication and dosage: ______________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

5. Please list and describe allergies and reactions to:

Medicine/Drugs: ___________________________________________________________________________________________________

Food/Plants/Other: __________________________________________________________________________________________________

Recommended treatment if allergy is severe? _____________________________________________________________________________

_________________________________________________________________________________________________________________

6. When did your child last see a doctor? Date__________________ Doctor’s Name ____________________________________________

Reason: ___________________________________________________________________________________________________________

7. While exercising, has your child ever had chest pain, light-headedness, fainting, or an irregular heart beat? ____Yes ____No

If yes, please explain: ________________________________________________________________________________________________

8. Females only: Is your daughter pregnant? ____Yes ____No Date of most recent menstrual period: _________________________

Parent/Guardian Consent

By signing this, I give permission to school personnel to share my child’s health /medical concerns, past and present, with school personnel on

an “as need to know” basis, unless I notify the school nurse in “writing” that I do not want it shared.

Date_________ Parent/Guardian Signature____________________________ Student Signature ____________________________________

Daytime Phone__________________ Cell Phone/alternate means of contact ____________________________________________________

NOTE: History and Consent MUST be completed prior to physical examination.

Form #030-3 1215 05-14-14 revised

For Grades

Six through

Twelve

To be completed by physician (MD, DO, CNP, or PA.):

PHYSICAL EXAMINATION (Please print or type)

Student’s Name___________________________________________________________ Birth Date _________________________________ Last First Middle

Sport __________________________________ Height ___________ Weight ___________ BP_______/_______ Pulse ________________

MEDICAL Normal Abnormal Findings Initials

Eyes/Ears/Nose/Throat _________ ____________________________________________________ _________

Lymph Nodes _________ ____________________________________________________ _________

Heart _________ ____________________________________________________ _________

Pulses _________ ____________________________________________________ _________

Lungs _________ ____________________________________________________ _________

Abdomen _________ ____________________________________________________ _________

Genitalia (males only) _________ ____________________________________________________ _________

Skin _________ ____________________________________________________ _________

MUSCULOSKELETAL Normal Abnormal Findings Initials

Neck ________ ____________________________________________________ _________

Back ________ ____________________________________________________ _________

Shoulder/Arm ________ ____________________________________________________ _________

Elbow/Forearm ________ ____________________________________________________ _________

Wrist/Hand ________ ____________________________________________________ _________

Hip/Thigh ________ ____________________________________________________ _________

Knee ________ ____________________________________________________ _________

Leg/Ankle ________ ____________________________________________________ _________

Foot ________ ____________________________________________________ _________

CLEARANCE

____Cleared for Contact Sports ____Cleared for Non-Contact Sports

____Cleared after completing evaluation/rehabilitation

for: ________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

____ Not cleared for: ________________________ Reason: __________________________________________________

Recommendations: ___________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

I certify that I have on this date examined this student and that, on the basis of the examination requested by the school authorities and the student’s medical history as furnished to me, I have found no reason which would make it medically inadvisable for this student to compete in supervised athletic activities (note exceptions above).

_____________________________________________________ ____________________________________________________ Physician’s Name (MD or DO) and Address (stamp or print) Examiner’s Signature

___________________________________________________________ __________________________________________________________

If the Physician’s Assistant (P.A.) or Certified Nurse Practitioner (C.N.P.) Date of Examination performed the examination, please stamp or print the name and address of the collaborating physician or physician group.

NOTE: History and Consent MUST be completed prior to physical examination.

Form 030-3 1215 09-16-11 revised

Sandusky City Schools EMERGENCY MEDICAL AUTHORIZATION

Purpose - To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school

authority, when parents or guardians cannot be reached. (In accordance with Ohio Revised Code 3313.712)

Student____________________________________________________ Sex: M F Birth Date_______________ HR/Grade________ Last First Middle

Address_______________________________ City________________ Zip Code________-_______ Phone______-______-_________

Residential Parent or Guardian: Yes No Residential Parent or Guardian: Yes No

Mother/Guardian_____________________________________ Father/Guardian_____________________________________

Address____________________________________________ Address____________________________________________

City______________________ Zip Code__________-______ City______________________ Zip Code__________-______

Daytime Phone____-____-_____ Cell Phone____-____-_____ Daytime Phone____-____-_____ Cell Phone____-____-_____

Home Phone____-____-_____ E-mail____________________ Home Phone____-____-_____ E-mail___________________

Place of Work_______________________________________ Place of Work_______________________________________

Dept.______________________ Phone_____-_____-_______ Dept.______________________ Phone_____-_____-_______

In case of emergency, when residential parent(s)/guardian cannot be reached, please contact local persons available during school hours.

Please seek permission from Emergency Contact persons before listing names and list in order of priority.

Other: Relative or Childcare Provider: Name Address Daytime Phone Relationship to Student

1. ________________________ _________________________ _____-_____-_______ ________________________

2. ________________________ _________________________ _____-_____-_______ ________________________

UUIIMMPPOORRTTAANNTT:: PPLLEEAASSEE DDOO NNOOTT CCOOMMPPLLEETTEE BBOOTTHH PPAARRTTSS,, PPAARRTT II UU OORR UUPPAARRTT IIII UU MMUUSSTT BBEE CCOOMMPPLLEETTEEDD.. U

PART I: TO GRANT CONSENT

I hereby give consent for the following medical care providers and local hospital to be called:

Doctor____________________________________________________ Phone________-________-____________

Dentist ___________________________________________________ Phone________-________-____________

Medical specialist___________________________________________ Phone________-________-____________

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed

necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and

(2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two

other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Facts

concerning the child's medical history including allergies, medications being taken, and any physical impairment to which a physician should be

alerted:

List all allergies and any special precautions or treatments for these allergies:____________________________________________________

__________________________________________________________________________________________________________________

List any medications currently being administered to the child:________________________________________________________________

__________________________________________________________________________________________________________________

List any health concerns or problems:____________________________________________________________________________________

__________________________________________________________________________________________________________________

By signing this, I also give permission to school personnel to share my child’s health/medical concerns (past/present) with school personnel on

an “as needed to know” basis, unless I notify the school nurse in “writing” that I do not want it shared.

___________________________________ ______________

Signature of Parent/Guardian Date

DDOO NNOOTT CCOOMMPPLLEETTEE IIFF YYOOUU HHAAVVEE CCOOMMPPLLEETTEEDD PPAARRTT II

PART II: REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. In the event of

illness or injury requiring emergency treatment, I wish the school authorities to take the following action:___________________________

_______________________________________________________________________________________________________________

By signing this, I also give permission to school personnel to share my child’s health/medical concerns (past/present) with school

personnel on an “as needed to know” basis, unless I notify the school nurse in “writing” that I do not want it shared.

___________________________________ ______________

Signature of Parent/Guardian Date

Form #005 1215 03-04-15 revised

SCHOOL YEAR

______ to ______

Reference information for Emergency Medical Authorization:

Ohio Revised Code ORC § 3313.71.2] § 3313.712 Emergency Medical Authorization: As used in this section, "parent" means parent as defined in HUsection 3321.01UH of the Revised Code.

A) Annually the board of education of each city, exempted village, local, and joint vocational school district

shall, before the first day of October, provide to the parent of every pupil enrolled in schools under the

board's jurisdiction, an emergency medical authorization form that is an identical copy of the form contained

in division of this section. Thereafter, the board shall, within thirty days after the entry of any pupil into a

public school in this state for the first time, provide his parent, either as part of any registration form which is

in use in the district, or as a separate form, an identical copy of the form contained in division (B) of this

section. When the form is returned to the school with Part I or Part II completed, the school shall keep the

form on file, and shall send the form to any school of a city, exempted village, local, or joint vocational

school district to which the pupil is transferred. Upon request of his parent, authorities of the school in which

the pupil is enrolled may permit the parent to make changes in a previously filed form, or to file a new form.

If a parent does not wish to give such written permission, he shall indicate in the proper place on the form the

procedure he wishes school authorities to follow in the event of a medical emergency involving his child.

Even if a parent gives written consent for emergency medical treatment, when a pupil becomes ill or is injured

and requires emergency medical treatment while under school authority, or while engaged in an extra-curricular

activity authorized by the appropriate school authorities, the authorities of his school shall make reasonable

attempts to contact the parent before treatment is given. The school shall present the pupil's emergency medical

authorization form or copy thereof to the hospital or practitioner rendering treatment.

Nothing in this section shall be construed to impose liability on any school official or school employee who, in

good faith, attempts to comply with this section.

(B) The emergency medical authorization form provided for in division (A) of this section is as follows: (see

reverse side of this sheet)

Form #005 1215 03-04-15 revised

http://onlinedocs.andersonpublishing.com/oh/lpExt.dll?f=FifLink&t=document-frame.htm&l=jump&iid=1d4a1037.1e1079a9.0.0&nid=82cf#JD_332101

Sandusky City Schools STUDENT AUTHORIZATION FORMS COMBINED

ACCEPTABLE USE POLICY and INTERNET SAFETY AGREEMENT

Statement of Purpose

Sandusky City Schools provides a rich information technology environment to support its educational activities. In order to provide for the most

effective access to computers, network and messaging systems and to protect the rights of students and staff, the following rules have been defined.

Access is a privilege, not a right, and carries with it responsibilities for all involved.

Terms of Agreement

In order for users to be allowed access to a school computer network and the Internet, parents and staff must sign and return the attached consent

form by the end of the first week of school.

User Responsibilities

The Sandusky City School district is providing access to its school computer network and the Internet for educational purposes only. To protect the

rights of students and staff, the following rules have been defined:

Users must:

1. Respect and practice the principles of good citizenship.

Prior to the start of class and again at the end, inspect equipment, including keyboards and mice, and report missing or damaged

equipment to the teacher.

Use care and respect when using equipment. No food, gum, drink or liquids of any kind are allowed near computers or in any

computer lab. Willful damage or vandalism to equipment or the data of any user is not permitted.

Use only teacher-managed educational networking sites (e.g. Moodle, ePals) and other forms of direct electronic communications

(e.g. email). Teacher management shall include enrolling and monitoring participation of students in online, interactive assignments.

Use technology resources for educational purposes only. The use of the network for profit-making (buying, selling, advertising),

political, religious illegal activities is prohibited. Illegal activities include tampering with computer hardware or software,

unauthorized entry into computers and files (hacking), and deletion of computer files. Such activity is considered a crime under state

and federal law.

Communicate only in ways that are kind and respectful. No swearing or suggestive, obscene, belligerent, bullying, harassing,

threatening language is permitted.

Use language and/or graphic representations which are not offensive to other users. The distribution, or redistribution of messages,

jokes, or pictures, which are based on slurs or stereotypes relating to race, age, gender, ethnicity, nationality, military status, religion,

economic status, political belief or sexual orientation is not permitted.

Do not send, forward or participate in chain letters or excessive use of email distribution (spam).

Report threatening or inappropriate communications to a teacher or network administrator immediately.

Access district supported email and if available, district supported voicemail daily (staff members only).

2. Respect and protect the privacy of self and others.

Keep username and passwords private. Do not disclose or share your password with others.

Do not post personal addresses, phone numbers, last names or photographs.

Do not use another student’s username or password. Do not impersonate another user.

3. Respect and protect the integrity, availability, and security of all electronic resources.

Lock or log off computer before leaving the computer station. Power down computer at the end of the day.

Maintain your document folder and remove outdated information.

Use of anonymous proxies to bypass content filtering is strictly prohibited and is a direct violation of this agreement.

Do not attempt to gain unauthorized access to another computer system (hacking) or to impair the operation of another computer

system (For example, the transmission of computer viruses, worms, etc.)

Do not store or install executable files (*.exe), batch files (*.bat), command files (*.com), system files (*.sys), zip/compressed files or

network files.

Obtain approval before retrieving information from a flash drive, CD, Internet location, or any other electronic media (students).

Do not use personally owned computers or other personal equipment on the network.

Do not install computer software or hardware. Only the IT department may install software or hardware.

Report security risks or violations to school or network administrator.

4. Respect and protect the intellectual property of others.

Adhere to the copyright laws of the United States (P.L. 94-553) and the Congressional Guidelines that delineate it regarding software,

authorship, and copying information. Do not infringe copyrights or plagiarize.

Form 019 1200/1216 Revised 06-24-16

Page 1 of 4

Failure to Follow Acceptable Use Policy

Use of the computer network and Internet is a privilege, not a right. It is the responsibility of the user to report misuse or violation of the network or

Acceptable Use Policy to the school or building administrator. The above rules and regulations of network usage are subject to change at any time.

Consequences for violations of the above policy will follow the District discipline policy and could result in the loss of a user’s privilege to use the

school’s information technology resources.

Internet Safety and Training

Despite every effort for supervision and filtering, all users and the students’ parents/guardians are advised that access to the electronic network

may include the potential for access to inappropriate materials. Every user must take responsibility for his or her use of the network and Internet

and report inappropriate sites to a school or network administrator.

In using the network and Internet, users should not reveal personal information such as home address or telephone number. Never arrange a

face-to-face meeting with someone “met” on the Internet.

Personally identifiable information concerning students may not be disclosed or used in any way on the Internet. Users should never give out

private or confidential information about themselves or others.

The District will utilize filtering software or other technologies to prevent students from accessing visual depictions that are obscene,

pornographic, or harmful to minors. Teachers may request to have educational sites reviewed and made available for classroom use through

application to the District Technology Department.

The use of anonymous proxies to get around the content filter is strictly prohibited and will be considered a violation of this policy. The school

will also monitor the online activities of users, through direct observation and technological means.

Internet Safety Training will be provided to students and staff in accordance with state guidelines.

Use of Web Tools

Online communication is critical to our students’ learning of 21st Century Skills. Tools such as discussion forums, wikis, and podcasting offer an

authentic, real-world vehicle for student expression. The District’s primary responsibility to students is their safety. Hence, student participation in

these types of classroom activities must follow all established Internet safety guidelines:

The use of discussion forums, podcasts or other Web 2.0 tools is considered an extension of the classroom. Only web tools initiated, managed

and monitored by teachers are permitted for use by students in classroom activities.

When using discussion forums, podcasts or other web tools, users are expected to act safely by keeping ALL personal information (including,

but not limited to, last names, personal details including address, phone numbers or photographs) out of their posts and account profiles.

Any speech that is considered inappropriate in the classroom is also inappropriate in all uses of discussion forums, podcasts, or other Web 2.0

tools. This includes, but is not limited to profanity, racist, sexist or discriminatory remarks.

Users who do not abide by these terms and conditions of the Acceptable Use Policy may lose their opportunity to take part in the project and/or

be subject to consequences in accordance to the school discipline policy.

Teacher Responsibilities with Use of Computer Labs or Mobile Labs

Provide appropriate opportunities to students using network and electronic information resources in support of the district curriculum for

educational purposes only.

Inform students of their rights and responsibilities as users of the district network prior to gaining access to that network.

Circulate, supervise and monitor student activities and report student infractions of the Acceptable Use Policy to the school administrator.

Provide alternate activities for students who do not have permission to use the Internet.

Check parental AUP permission forms before submitting photos or artwork for publications (newsletter, websites, etc.). Do not publish student

name with photos.

Principal Responsibilities

Distribute the Acceptable Use Policy to all students.

Keep signed Acceptable Use Policy forms on file.

Treat student infractions of the Acceptable Use Policy according to the school discipline policy.

Provide a list of students who do not have permission to use the Internet to the teaching staff and IT Department.

District Responsibilities

The Network Administrator and other authorized administrators will:

Ensure that filtering software is in use to block access to materials that are inappropriate, offensive, obscene, or contain pornography.

Review requests from teachers for access to currently filtered educational sites and open access to sites which are deemed safe.

Review the board approved Acceptable Use Policy annually.

Monitor system resources to ensure that uses are secure and in conform to this policy. Administrators reserve the right to examine, use, and

disclose any data found on the school’s information networks in order to further the health, safety, discipline, or security of any student or other

person, or to protect property. This information can be used for disciplinary action and can be furnished as evidence of crime to law

enforcement officials.

Page 2 of 4

Sandusky City Schools STUDENT AUTHORIZATION FORMS COMBINED

Please return this packet completed. (Sections require initials, additional information, and a signature at the end.)

Student Name _____________________________________________ 20____ - 20_____ (Please print) (School Year)

Below are forms that have been combined for space and convenience. Please review and initial each section:

ACCEPTABLE USE POLICY AND INTERNET SAFETY AGREEMENT I have read and understand the Acceptable Use Policy and I agree to the following:

Initial each to indicate acceptance:

_____ As the parent or legal guardian of the student named above, I grant permission for my son or daughter to access use a school

computer or network software provided by the Sandusky City Schools.

_____ As the parent or legal guardian of the student named above, I grant permission for my son or daughter to access Internet

services provided by the Sandusky City Schools.

_____ As a parent or legal guardian or the student named above, I grant permission for my son or daughter’s school work to be

published without identifying name or caption to appear on the any district, school, or teacher website connected with the

Sandusky City Schools.

REPRODUCTION OF STUDENT PHOTOGRAPHS, AUDIO, VIDEO, AND LIKENESS At times Sandusky City Schools reproduce photos, audio, video, likenesses, and names of students to acknowledge credit and for the

benefit of the community. Some examples may be: annual calendar, newsletter, website, live or recorded audio/video, and video

broadcasts, as well as athletic, music and theatre presentations. This would include interactive and web based learning broadcasts

sponsored by the district with sites outside the school district. Sandusky City Schools does not distribute the reproduction of student

photos, audio, video, likenesses, or names to any other entity, unless expressly approved by a parent or guardian.

Initial ONE to indicate acceptance:

_____ I authorize the reproduction of my child’s photo, audio, video, likenesses, and name for presentation

by the Sandusky City Schools. This authorization supersedes the FERPA student records act only for the items listed.

_____ I do not authorize the reproduction of my child’s photo, audio, video or likeness.

REPRODUCTION OF ORIGINAL STUDENT PRODUCED WORK At times Sandusky City Schools reproduces original student work, photos, audio, video and names of students to acknowledge credit

and for the benefit of the community. Some examples may be: annual calendar, newsletter, website, live audio and recordings, and

video broadcasts, as well as athletic, music and theatre presentations. Original Student Work is considered items that are physical,

visual, and audio. Sandusky City Schools does not authorize reproduction of original student work to any outside entity for the benefit

of fund raising or entities outside the school district’s jurisdiction unless expressly approved by a parent or guardian.


_____ I authorize the reproduction of my child’s original student work, photos, audio, video and name for the purpose of presentation

by the Sandusky City Schools. This authorization supersedes the FERPA student records act only for the items listed.

_____ I do not authorize the reproduction of my child’s original student work, photos, audio or video.

Please turn over and complete the back of this form.

Page 3 of 4

Sandusky City Schools

STUDENT AUTHORIZATION FORMS COMBINED (Continued)

EMERGENCY CLOSING AUTHORIZATION - KINDERGARTEN THROUGH SIXTH GRADE In the event school is closed prior to the regular dismissal time, due to an unexpected emergency, I want my child to remain under the

supervision of Sandusky City Schools until I can be contacted by school staff. I understand that my child may be moved to a safe

location if necessary.


____ I authorize my child to remain under Sandusky City Schools supervision until I can be contacted.

____I authorize my child to be dismissed without contacting me.

FIELD TRIP PERMISSION My child has permission to participate in all field trips sponsored by Sandusky City Schools. I understand that I may withhold

permission for any field trip in which I do not want my child to participate by notifying the school in “writing.”


____I authorize this Field Trip Permission.

____I do not authorize this Field Trip Permission. I understand that I may authorize my child in writing as trips become available.

CHILD PICK-UP AUTHORIZATION If my child needs to be picked up from school, the following names are the only people I authorize to pick up my child.

Name _______________________________________________________ Phone _______-_______-_________ _____ Initial







PARENT/GUARDIAN SIGNATURE As the parent or legal guardian of the above student, I have read, understand, and agree that my child shall comply with the terms of

the Sandusky City Schools Acceptable Use and Internet Safety Agreement. In addition, I have initialed items in each of the above

Student Authorization Forms.

__________________________________________ ____________________ Signature of Residential Parent/Guardian Date

Please sign and return this form the first week of school. Page 4 of 4