Parent Signature. Yes, I give consent for Jefferson School District to access my public benefits for my child’s health services. No, I do not give consent for Jefferson School District to access my public benefits for my child’s health services. If you do not wish directory information released, please sign where indicated below and return to the school office within the next 30 days. Note that this will prohibit the District from providing the student’s name and other information to the news media, interested schools, parent-teacher associations, interested employers, and similar parties. Do NOT release directory information regarding (Pupil’s Name) □ Check if an exception may be made to include student information and photos in the yearbook. I hereby acknowledge receipt of information regarding my rights, responsibilities, and protections . Student Signature Date Parent/Legal Guardian Signature Date
Parent Signature. I declare, under penalty of perjury, that I will adhere to the requirements outlined above and that all information provided is true and accurate. I understand that I have not been officially approved for services until I receive my Notice of Action (NOA). Parent/Guardian Signature Date
Parent Signature. (Name in print) ............................................ Date ............................................
Parent Signature. Date: *Dates may be modified at the discretion of the coordinator due to state reporting requirements. In the event of a change, the modification will be noted in this agreement with advanced notification given to the student and assigned mentor teacher. Mentor Teacher Contact I agree to maintain two-way communication with my assigned mentor teacher on a weekly basis throughout my enrollment (exceptions during winter and spring break only). I agree to meet at my predetermined times and dates, either at the resident district or by telephone, once per week with my assigned mentor teacher. This arrangement is made between my assigned mentor teacher and me upon my enrollment.
Parent Signature. Date: .........................................
Parent Signature. In school it is important that I work to the best of my ability. In order to do this, I will try to do the following: Do my best in my work and behavior. Show my parents the contents of my book bag every day. Come to school each day with pencils, paper and other necessary tools for learning. Complete and return homework. Limit the amount of time spent playing video games and watching television. Attend school each day and be on time. Not argue or fight. Be honest and fair. TEACHER AGREEMENT: Student Signature It is important that students achieve. Therefore, I shall strive to do the following: Show that I care about all students. Have high expectations for myself, students, and other staff. Provide a safe environment for learning. Provide assistance to parents so that they can help with assignments. Encourage students and parents by providing information about student progress. Use special activities in the classroom to make learning enjoyable. Seek ways to involve parents in the school program. Show respect for each child and his/her family. PRINCIPAL AGREEMENT: Teacher Signature I support this form of parent involvement. Therefore, I shall strive to do the following: Provide an environment that allows for positive communication between the teacher, parent, and student. Act as the instructional leader by supporting teachers in their classrooms. Provide appropriate in-service and training for teachers and parents.
Parent Signature. I agree that I will provide the babysitter with diapers, extra clothing, special food, or any other necessary items. I agree that I will also provide the babysitter with instructions regarding feeding schedules, nap and bedtime schedules, and any other necessary instructions to care for my child(ren). I understand that by signing this form, I am trusting my child(ren)’s safety and welfare to the above named babysitter, and that I am holding the shelter, hotel or other EA placement and DHCD harmless if my child(ren) is(are) injured or not cared for as I would like. Parent Signature:
Parent Signature. Date:……………………………………………………………………………………………………………………………………………………………………………….......
Parent Signature. Provider Signature: Permission for Outdoor Activities The Provider, Steps to Success , and the staff of Steps to Success may take my child for any activities checked below as part of the Preschool Program: On site playground Short walking trips __ __ __ ___ Parent Signature: Address: Phone Number: Date: To: School# Class# To Whom It May Concern: I, parent of _ _, am g1vmg pernuss10n to Steps To Success to pick up my child from school and return to their Afterschool Program. If you have any questions, please contact me at: Thank you, Signature of Parent/Guardian
Parent Signature. Print name: ..............................................................................
