St latnzs ,frgfL ScJwo[ 108Cf rfuy 707 Mune[k Infzt, SC

St latnzs ,frgfL ScJwo[ 108Cf rfuy 707 Mune[k Infzt, SC

St latnzs,frgfLScJwo[
108Cfrfuy 707
Mune[k Infzt, SC29576
843450-21A
843450-2M2fa<
New Student Checklist
Introducing the GuidanceOffice Staff
TonyaPickett 650-1046 Kelli Schwartzkopf 650-1749
GuidanceCounselor
Directorof Guidance
JimKneece 650-1117
Counselor
Guidance
AngelaGoss 650-1171
Facilitator
CareerDevelopment
Lizlntnen 650-2245
Counselor
Guidance
BarbaraHamby 650-2104
GuidanceSecretary
The following witl needto be completedto enroll a student:
Releaseof StudentRecordsForm (PreviousSchoolRecords)
StudentParentInformationDECI sheet
McKinney-Vento-ActIdentificationForm
(Only Proof of ResidencyAccepted)
Proof of ResidencyForm
PhoneBill
Current Water Bill
Cable Bill
Current Electric Bill
Rental Agreement
Mortgage Agreement
Birth Certificate
ImmunizationRecordwith HepatitisSeries
SocialSecurityCard
or Report Card showing 8'nGradePromotion
Final Transcript(9th-12th)
to 9'nGrade
PLEASE NOTE: If your child or children do not have a Withdrawal Form from
their previousschool,they will not be able to enroll at this time.
Each student is expectedto abide by all Policiesand Proceduresset forth by the
Horry County School District. All information with regards to policies,procedures
and general information can be found in the Parent and Student Handbook which
studentswill receiveon their first day of school.The information can also be
on the Horry County Website at www.horrycountyschools.net
accessed
THIS FORM IS TO BE COI\,IPLETEDAND RETURNED
St.JamesHigh Registrationand FeeChecklist
Date:
Grade:
MiddleInitial:
FirstName:
LastName:
Please check belotuall itents that are attached. If the items do not qpply to lhe studentlisted abottewrite N/A
besidethe item.
_Registration
Amount
Fee-required$12.00
CompletedStudentRegistrationForm-required
AdditionallEmergency
ContactForm-requi red
CurrentProof of residencyForm and residencypapers-required
CompletedLanguageSurveyForm-required
CompletedMcKinney-Vento-ActIdentificationForm-required
CompletedAdditionalVerificationof ResidencyForm-required
CompletedHealthInformationForm-required
Amount
ROTC Fees$25 00
_PTSO
Amount
MembershipFee$10.00
YearbookFee$65.00
Amount
Fees Owed from previous school year (Must be paid to completeregistration)
Amount
Total payableto St. JamesHigh School
Total Amount $
Studentsneedto return their registrutionpucketsto scltoolby Muy 7,2010.
St.JamesHieh School
10800]Hiy 707
MurrellsInlet,SC.29575
Fax(843)650-1004
For BookkeeperUse Only
SraffInitials
Date Received
Confidential
Horry CounfYSchools
Transferof StudentsRecords
St. JamesHigh School
10800IJwY 707
Murrellslnlet,s C 29576
Phone:(843) 650-2L04
Fax: (843) 650-2042
School Last Enrolled
SocialSecurityNumber
Student'sName
Grade
Dateof Birth
No
only)YesIs the studentcurrentlyin the SSTProcess?(Elementary
If yes,pleaseforward the interventionplan alongwith thecumulativerecords.
No
YesDoesthe studenthavea 504Plan?
records'
If yes,pleasesenda iopy of tn. S04Planalongwith thecumulative
Yes-
Doesthe studenthavea curuentIEP?
No-
If yes,pleaseforward tn.lEp ulo"g with the cumulativerecords.Follow the establishedspecial
educationproceduresfor transferringrecords.(Forms are online at the district's website under
SpecialEducation: Form #'s ACC-|, ACC-7 and ACC-B)
Transfer of records should contain the following information:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Official Transcript of Grades/ PermanentRecords
Withdrawal Form with transfergradesfor the cunent year
Health/ImmunizationRecords
Printout of Discipline Record
Printout of AttendanceRecord
StandardizedTest Scores
Copy of Birth Certificate
Copy of SocialSecurityCard
ApplicableLegaVCourtDocuments
Parent/Guardian Si gnature
Date
RecordsClerk/Designee
Date
A copy of this "Transfer of Stadent Records"form
must be kept on Jile in both the sending and receiving schools.
9-15-04
N DR E T U R N E D
T H I SF O R MI ST O B EC O M P L E T EAD
St.JamesHighSchool
10800Highway707
MurrellsInlet,SouthCarolina29576
Main Office843-650-5600
FORM
STUDENT
REGISTRATION
201,0-201,IGrad
e Level:
Date:
LastName:
H o m eP h o n e # :
M i d d l eN a m e : _
First Name:
DOB:
SSN#;
Ethniciw:
State:
ZipCode:
M a i l i n gAd d r e ss:
City:
Street Address[if differentfrom above):
State:
City:
ZipCode:
Parent/Guardian Information
Relationship:
# lP ar ent/ GuardianName:
L a n dL i n e H o m e # :
Work#:
Cell#:
E m a i la d d r e s s :
Studentliveswith #IParent/Guardian:Yes_
No_
#2Par ent/ GuardianName:
L a n dL i n e H o m e # :
Relationship:
Cell#:
E m a i la d d r e s s :
Studentliveswith #2ParentGuardian:Yes
No-
OVER
Work#:
Sex:
AD
N DR E T U R N E D
T H I SF O R MI ST O B EC O M P L E T E
St.JamesHighSchool
10800Highway707
MurrellsInlet,SouthCarolina29576
Main Office843-650-5600
CONTACTFORM
ADDITIONAT/EMERGENCY
Additional/EmergencyContactInformation other than parent/guardian
*Pleasenote: In any situation when parents/guardianscannotbe reached,the following contacts
may act on the parents/guardiansbehalf.
# 1 Additional/EmergencyContact
Relationship:
Name:
Land Line Home #:
Work#r
Cell#:
#2 Additional/Emergency Contact
Relationship:
Name:
Land Line Home #:
Work#:
Cell#:
# 3 Additional/EmergencyContact
Name:
Land Line Home #:
Relationship:
Cell#:
Work#r
THIS FORM IS TO BE COMPLETBD AND RBTURNED
St,JamesHigh School
10800Hwy 707
5
MurrellsInlet,SC.295'1
MainOffice(843)650-5600
PROOFOF RESIDENCY
GRADE:
STUDENTNAME:
Pleaseattachto this sheeta copy ofacceptableaddressverification,a currentcablebill,
an electricbill, a telephonebill, a waterbill, a mortgageagreementor a signedrental
agreement.Thesearethe ONLY proofsof residencythat will be accepted.These
name, Documentswith ONLY
MUST showa physicaladdressandthe parent/guardian
a P.O.Box will not be accepted.
Pleasecheckwhich type of proof you provided.
Acceptableaddressverificationshouldbe provided in one of the followingforms:
Current Utility Bill (Wateri Electric/PhoneiCable)
(Service location, name and addressMUST be on the bill presented.)
Notarized letter verifying residencycombinedwith a copy of utility bill from
landlord or personwith whom the student is living.
agreementshowingphysical
Current signedrental/lease/sales/construction
addressof property (must be signedby both parties).
Approved transfer letter.
Proof of Guardianshipif studentis living with grandparent,etc... (Copy of
guardian'sproof of addressmust accompanypaperwork).
Current valid receiptAND letter on property letterheadindicating studentis
staying in a hotel or rental condofor long term (must show location of property).
PROOF OF RtrSIDENCY: Falsificationof any of the following information will
result in immediatereassignment
of this student. Current addressand phone
numberswill be verified.
OVER
A D D IT IONALVERIFICATION
OF RESIDENCY
Vehiclelnfor mation
havebeenmade,my child'sprimary
I understand
that,unlessspecialarrangements
residencemust be in Horry County,South Carolina,in order for me to register
( C h i l d ' sF u l lN a m e ) ,i n
School.
for vehiclesowned by our family
The licenseplate numbersand state of registration
memberswhichmay be drivenor parkedon schoolgroundsare as follows:
VehicleTag
Number
in S.C.,
Stateof Vehicle lf vehicleis registered
in HorryCounty?
Registration is it registered
Yes.
in
No.registered
County
Yes.
in
No:registered
County
in
County
_Yes. _No: registered
, k addr ess,and t el ephone
M y s t r e e ta d d re ss(a P .O.B o x addr essis not acceptable)wor
a re a s fo l l o w s:
n u m b e r(s)
Streetaddress:
City,StateZip
H o mete l e p h o n e :
Workaddress:
City,StateZip
Worktelephone:
may be usedby HorryCountySchoolsor
that the foregoinginformation
I understand
of determining
residency
for purposes
agencies
stateor county
sharedwithappropriate
which
and for complyingwith South Carolinastatutes,includingSection56-3-210,
purchased
or
vehicle
or
a
moving
vehicle,
person
or
used
acquiring
a new
requiresa
"permanent"
plate
on the
license
outsideS.C. into this state,to placea
registered
provided
law,
by
otherwise
unless
days
calendar
within
forty-five
vehicle
Signatur e.
Pr intNam e:
Date:
for studentpar kingat St. J am es
N O T E :T h i s fo rm i s N OT a p ar kingper mitapplication
form requiredby the district.
High. This.formis a residencyinformation
Adopted: 6-25-02. Revised: 7 -1-04;124-07.
Horry
Schools
Gounty
forNewStudents
Language
Survey
BY,SCHoOt-,
..1
...l,to.gn'CdMpurrno,
enrollinq
at vourschoolcomplete
Haveeverynewstudent
thisform.
to Questions
1,2,or 3 is anylanguage
otherthanEnglish
ff theanswer
to Questions
1,2,and3 is English
lf theanswer
Date:
Today's
SASINumber:
School:
pnnerul.oi.STUneruf.lG,naorS.6.tit.l
-.f.fo.er'Corrltpl-eiro,eV.
FirstName
Student's
Student's
LastName
Student's
MiddleName
Ethn
American
n African
Indian
Am./Am.
n African
Indian
n American
Gender
lslander n White/Am.Indian
Ll Hawaiian/Paciflc
I Hispanic
I White/Asian
n White
mm_dd
n Other
English
WhatIanguage
doesthestudent
mostoftenspeak?
n
n
Whatlanguage
ismostoftenspoken
inthestudent's
home?
!
thestudent
1 . Whatis thefirstlanguage
learned
tospeak?
L.
4.
country
Whatisthestudent's
of birth?
5
firstentera school
Whendidthestudent
intheUSA?
n Male
I
American
n White/African
Asian
a
yy
Spanish
Female
Other(specify)
n
n
n
Month
_Day_
Year
Nameandlocation
oftheschool
lastattended:
(Grades
Signature
Parent's
K-5):
Date:
(Grades
Student's
Signature
6-12):
Date:
$.ro'BEic0ttpurr-Eb.
rrnduEn.
.EV..iSot.
.'0
DateTested
DoestheStudent
Qual for Services?
ESLCode:
OVER
-----ESOU2006-07
-English.doc
geSurvey
Revised
212006
ESOL Form01O-English
Langua
Escuelas
deHorry
delCondado
para
estudiantes
Encuesta
sobreidiomas nuevos
.,.'$'ro.bE.coMpLETED.
b'V.
Scttoot-,r$
thisform.
atvourschoolcomplete
Haveevervnewstudentenrollinq
otherthanEnglish
to Questions
1,2,or 3 is anylanguage
lf theanswer
1,2,and3 is English
to Questions
lf theanswer
Today's
Date:
SASlNumber:
School:
.f Porr.fivoi.iespOnua.
en,1ng16s.:$
o Nombre
os delEstudiante
Genero
Masculino
Femenino
denacimiento
Fecha
Etnicidad
Mes_dia
_ano
Ingl6s
queelestudiante
a hablar?
aprendio
idioma
1 , iCudleselelprimer
queelestudiante
hablaconmasfrequencia?
2 , iCualesel idioma
delestudiante?
enel hogar
sehabla
conm6sfrequencia
3 . iQu6idioma
Espanol
0tro
n
n
n
u
T
T
delestudiante?
4 . iOudleselpaisdenacimiento
5
porprimera
vez?
Unidos
delosEstados
enunaescuela
elestudiante
sematriculo
; Cu6ndo
Mes_dia_
ano
queasistio:
y lugar
escuela
delaultima
Nombre
(Grado
K'5):
delospadres
Firma
Fecha:
(Grado6-12):
Firmadelestudiante
Fecha:
.Lio,eEcorvrPtgreo,
r,rEAcHER,
et,ESo
:.1
DoestheStudent
Qu
DateTested
for Services?
No
tr Yes,
ESLCode:
,
Survey-Spanish
Language
Revised
B/06-ESOU2006-07
ESOLForm010-spanish
McKinney-Vento-Act Identifi cation Form
Federal McKinney-Vento Assistance Act ensures education rights and protections for children and youth
experiencing housing dfficulties or loss of housing. In order to serve these students in every way available, we
need to identifu those in situations that ntay qualify. Please complete thefollowing:
School
StudentName
Grade
Teacher
PowerSchoolID #
Pleasecheckoptionfor the studentbeingenrolled:
A.
has a fixed, regular and adequatenighttime residenceand is not temporarilysharinghousing
(Pleasesupply proof of residencefor new students.)In this situation, the family is NOT
ooA"is checked,do not check any
consideredhomelessand the form will be discarded. If
optionsbelow.
B
Explainsituationif possible.
doesnot have a fixed, regularandadequatenighttimeresidence.
C.
includingrelatives
or friends,dueto.
is temporarily
sharingthe housingof otherpersons,
lossof housing,_
D
economichardshipor
is living in temporary housing (motel,camper,emergencyshelter,etc.)in places
or
not ordinarilyusedas regularsleepingaccommodations,
is living in substandardhousing(lack of hot or cold water,flushtoilet, electricity,etc.)
E.
is unable to live with a parentor legalguardiandue to family difficulties.
Pleaseexolainif oossible:
School(s)child previouslyattended(if any)
Documentsnot available:
Birth Certificate
SocialSecurity
Immunization
Reasondocument(s)not available.
Are other children in the home enrolled in Horry County Schools?
attended.
If yes,pleaseprovidethename(s)andschool(s)
yes-no
The administration of the Florry County School in which the child attends is responsiblefor submitting the forms.
Name(s)
School(s)
children in the home?
Are preschool-aged
yes
If yes,what are their names& ages?
Daycare or preschgolthey attend:
Date
SchoolPersonnelSignature
,9thmit
thi.c form tn C.nrnlvn C.hp.gtnuf thc Di.ctrict Hnmple.cc [,inisnn
Rptt R/0R
Forma de Identificaci6ndel Acto de McKinney-Vento
experintentandificultades en sus viviendas 6 pdrdida de su vivienda. Para servir a estos estudiantesen todos los
puedancalificarpara estaayuda.Porfavor
identificara aquelloscuyassituaciones
aspectosdisponibles,necesitantos
contpletela siguientefornta:
Escuela:
Nombre del Estudiante:
PowerSchool
ID #
Grado:
Maestro:
Por Favor marque TODOS los que aplican para el AL estudianteque estasiendoinscrito
A.
por favor
tiene una residenciaapropiada,regulary fUa durantela noche.(Paranuevosestudiantes,
como una
sumitaSUBMITApruebade residencia).En estasituaci6n,la familia NO estaconsiderada
familiasinhogar.
B
regularo fija durantela noche.Expliquela situaci6nsi es posible:
no tiene una residencia
adecuada,
C
est6compartiendotemporalmente la residencia de otra persona,incluyendoparienteso amigos,
dificultad econ6mrca.
vivienda,
perdida
de
P6RDIDA
debido a:
6 offa
D
estaviviendoen unaviviendatemporal en lugaresqueno sottusadospor lo generalcomohospedajes
paradormir,6
normalesconacomodaciones
refugiode emergencia
Motel
autocaravana
E.
esta viviendo el1una vivienda de calidad inferior (falta de agua caliente o fria, falta de electricidad,
etc.l
F.
esta incapacitado de vivir con uno de los padres de familia 6 con un guardian legal debido a
Expliquela situacionsi esposible:
familiares.
dificultades
Escuelaspreviamente asistidaspor el niiro(a) (si hubo alguna)
Documentosno disponibles
Certificadode Nacimiento
Vacunas
SeguroSocial
no est6Ln
disponibles
Raz6npor la cual los documentos
Distrito Escolar
Hay otros niiios en la casainscritosen
sl
Su(s)Nombre(s)
Escuela(s
Hay nifios de edad pre-escolaren su casa
si
no
LA RESPUESTAES sio;Cudlessonsusnombresy edades?
Guarderia 6 pre-escolar al cual ellos asisten
Firma del Personal del Distrito/Escuela
Presenlar estafonna aJ distt"ilo de Enlace Sin Hogar
Fecha
no
THIS FORM IS TO BE COMPLETED AND RETURNED
Student Health Information Sheet
Student'sLegal Name:
Date of Birth:
Grade for 20 I 0-20I I Year:_
Nickname:
******+*******+*****************************************+******************************************************8**+********************
EMERGENCY INFORMATION
Home Phone:
ParenVGuardianNatne:
Address
Cell Phone:
N{other'sErnployer:
Work Phone:
Father'sErnployer
Work Phone:
I n c a s e o f a n e m e r g e n c y , S J H S w i l l m a k e e v e r y e f f o n t o c o n t a c t t h e p a r e n It n
. caseaparentcannotbereached,pleaselistotheremergencycontactpersons:
Name:
Relationship
Phone#:
x**sShould you have any specialinstructionregardingthe releaseofyour
child, pleaseprovidc detailedinformalion on the back oflhis sheet.+***
No
Yes
Telephone
Physician
Alerts:
**********t******************t******+*****t+++*++**++*+***************************f**+****+tf,+********t***+**+*+t******+t*t+++*+*****tl
co
Pleaseindicateanyofthefollowingmedica
l n d i l i o n s t h a l h a v e b e e n d o c u m e n l e d b y a p h y s i c i aAni.l i n f o r m a l i o n i s c o n f i d e n t i a lT. h e s c h o o l n u r s e w i l lu s e t l . r i s
information in planningthe healthneedsof'the studentsand updatingthe student'sheallh record.
Pleasecheck lrns$'ersto the following questions in columns on the left. (llxplain all "yes" answersin the space provided below.)
No
Yes
t.
n
f]
r T
Do you have any concemsabout your cl.rild'sgeneralhealth(overall eating and sleepinghabits,teeth,etc.)?
Has your child been diagnosedwith any clronic diseases?
!
A.th-u - Does your child needan inhaler at school?
f
Diob"t"r- Does your child needto glucoselest or injecl insulin at school? Yes
l-l
Yes
S"irur.-DoesyourchildtakeseizuremedicationY
? es
No
No
No
- - - - - - D a l eo f l a s t s e i z L r r e _
l-l oth"r'
n
T
Does your child have any allergies(food, insects,medication,lalex, peututs, etc.)?
-------Doesyour child require an Epi pen at school?
Yes
No
f
I
Does your child take any medications(daily or occasionally)?lf so, pleaselist below.
f
l
Does your child have any problemswilh vision, hearingor speech(glasses,contacts,eartubes,hearingaid, etc)?
6.
I
I
Has your child had any hospitalization,operation,major illness or injury, or significantaccidenl?
7
I
I
y#"fi::l]l*'Jffffi:X;?il,:iT'jilt",f,,'jn
S
f]
I
Would you like to discussany4hingabout your child's healthwith the schoolnurse?
coughing'
excessive
excessive
gain'or
*n""i"t' excessive
nightrT'aking'
weight
lossorweight
P l e a s e e x p l a i n a n y " y e s " a n s r v e r s h e rFeo. r i l l n e s s / i n j u r i e s / e t c . , i n c l u d e t h e y e a r a n d / o r y o u r c h i l d ' s a g e a t t h e t i m e .
I give pemission for releue of infomation on this fom for confidentialue in meetingmy child's health and educationalneedsin school. Shouldan emergencyarisein which time is m
also give pemissio
Sisnature of Parent/Guardian
Date
HORRYCOUNrySCHOOLS
O f f i c eo f S p e c i a E
l ducation
P O B o x 2 6 0 0 0 5C o n w a y ,S C 8 4 3 - 4 8 8 - 6 9 3 3
Medicaid Release of Information
Updated July 1, 2008
Form MC-1
and MedicaidReimbursement
Consentfor Treatment,
of lnformation,
Release
S t u d e n t 'Fs u l lN a m e
Date of Birth
School
P a r e n t ' sN a m e
S t u d e n t ' sS o c i a lS e c u r i t vN u m b e r
S t u d e n t ' sM e di c a i dN u m b e r
H o r r yC o u n t yS c h o o l sa n d t h e S o u t hC a r o l i n aD e p a r t m e not f E d u c a t i o nh a v e m y p e r m i s s i o tno p r o v i d eh e a l t h - r e l a t e d
l f o r m a t i o na,s n e c e s s a r yt,o t h e
s e r v i c e st o m y c h i l d a n d t o r e l e a s ea n d e x c h a n g em e d i c a la n d o t h e r c o n f i d e n t i ai n
D e p a r t m e not f H e a l t ha n d H u m a n S e r v i c e sa n d a n y t h i r d p a r t y i n s u r a n c ec a r r i e rr e g a r d i n gh e a l t h - r e l a t esde r v i c e s
l i s t r i c t / a g e n c y wpi rl lo v i d e
p r o v i d e dt o m y c h i l dp r i o r t ot h e d a t eo f t h i s c o n s e n o
t r t h e r e a f t e r f osr e r v i c e st h a t t h e s c h o o d
inthe future.
B y s i g n i n gt h i s f o r m , I g i v e H o r r yC o u n t yS c h o o l sa n d T h e S o u t hC a r o l i n aD e p a r t m e not f E d u c a t i o nm y p e r m i s s i o tno
b i l l M e d i c a i da n d a n y t h i r d p a r t y i n s u r a n c ea n d r e c e i v ep a y m e n tf r o m M e d i c a i do r a n y t h i r d p a r t yi n s u r e rf o r h e a l t h r e l a t e ds e r v i c e sa s s e t f o r t h i n m y c h i l d ' si n d i v r d u a l i z eedd u c a t i o np r o g r a m( l E P ) , a n d f o r p s y c h o l o g i c aelv a l u a t i o n
s e r v i c e sn, u r s i n gs e r v i c e ss, c h o o lb a s e dm e n t a lh e a l t hs e r v i c e sa, n d o t h e rh e a l t h - r e l a t et rde a t m e nst e r v i c e sb i l l a b l et o
M e d i c a i dw i t h o u t h e r e q u i r e m e notf a n I E P
f ot r h e a l t h - r e l a t esde r y i c e sp r o v i d e db y H o r r yC o u n t yS c h o o l sa n d t h e S o u t h
I u n d e r s t a n tdh a t M e d i c a i dr e i m b u r s e m e n
n i l l n o t a f f e c ta n y o t h e rM e d i c a i ds e r v i c e sf o r w h i c hm y c h i l di s e l i g i b l e .I u n d e r s t a n d
C a r o l i n aD e p a r t m e not f E d u c a t i o w
t h a t m y c h i l dw i l l r e c e i v et h e s e r v i c e sl i s t e di n t h e I E P r e g a r d l e sosf w h e t h e rI e n r o l lm y c h i l di n p u b l i co r p r i v a t eb e n e f l t s
t h a t m y r e f u s a tl o a l l o w a c c e s st o t h e D e p a r t m e not f H e a l t ha n d H u m a n
o r i n s u r a n c ep r o g r a m s . l a l s o u n d e r s t a n d
S e r v i c e so r a n y t h i r dp a r t yi n s u r a n c ec a r r i e rd o e s n o t r e l i e v et h e D i s t r i cot f i t s r e s p o n s i b i l it oy e n s u r et h a t a l l r e q u i r e d
s e r v i c e sa r e p r o v i d e da t n o c o s tt o m e .
I u n d e r s t a n dt h a t t h e g r a n t i n go f c o n s e n ti s v o l u n t a r yo n m y p a r t a n d m a y b e r e v o k e da t a n y t i m e . l f I l a t e rr e v o k e
c o n s e n t t, h a t r e v o c a t i o ni s n o t r e t r o a c t i v (ei . e . ,i t d o e s n o t n e g a t ea n a c t i o nt h a t h a s o c c u r r e da f t e rt h e c o n s e n tw a s
g i v e na n d b e f o r et h e c o n s e nw
t as revoked).
w i l l o p e r a t eu n d e rt h e
t h a t H o r r yC o u n t yS c h o o l sa n d t h e S o u t hC a r o l i n aD e p a r t m e not f E d u c a t i o n
I also understand
g u i d e l i n e so f t h e F a m i l yE d u c a t i o n aRl i g h t sa n d P r i v a c yA c t ( F E R P A )t o e n s u r ec o n f i d e n t i a l i rt ye g a r d i n gm y c h i l d ' s
treatmentand Drovisionof healthrelatedservices.
Date
Signature
fl Parent
fl Guardian I
parent I
Surrogate
Student
if over18