District ConsentForm
School Year: ______
StudentLastName,FirstInitial:
PARENT/GUARDIANSIGNATUREPAGE
Please readthesupportingdocumentsinthestudenthandbook so you are familiar with the district’s policies and procedures. Acopyofthisform willbeprovided foryouatyour child’sschooland/orontheschoolwebsite.Thissignedformwillbekeptonfileintheschooloffice.
I,theundersignedparent/guardianofthenamedstudent, confirm that Ihavetheparental/guardianshipauthoritytoexecutethisform. I acknowledgethatIunderstandthefollowingnoticesandprovidemyconsentorIdecline asindicatedbelow:
DisciplineCodeand Procedures
Iunderstand a copy of the Des Moines Independent Community School District’s handbook will be provided to me by my student’s school or is available on the website. I acknowledge that I will review this handbook as my child is expected to follow the district’s Discipline Code and Procedures.
(Signatureofparent/guardian)Date ______
NetworkAcceptableUseGuidelines
Astheparent/guardianofthisstudent,Iconfirm I am aware there is aDMPSAcceptableUseGuidelinesto which my child is expected to adhereandI understandthataccesstothenetworkisintendedforeducationalpurposes. IunderstandthatDMPShastakenprecautionsto eliminateinappropriatematerial;however,IalsorecognizeitisimpossibleforDMPStorestrictaccesstoallinappropriate materialsandIwillnotholdDMPSresponsibleformaterialsacquiredonthenetwork. Furthermore,Iacceptfullresponsibilityforsupervisionif andwhenmychild’s useisnotinaschoolsetting. Iherebygivepermission toDMPStoprovidenetworkaccessformychildand ce1tifythattheinformationcontainedonthisformiscorrect. Iunderstandthatmystudentmustalsosignanetworkagreement consentform.
______(Signatureofparent)Date
Videoand MediaConsent
Iconsenttoallowingmychildtobevideotapedwhileatschoolandtheirphototakenbydistrictemployeestobeusedfordistrict relatedpurposes.
(Signatureofparent/guardian)
Iconsenttoallowingmychildtobeinterviewedorphotographedbymediarepresentatives(suchastheDesMoinesRegister)who arenotemployeesofthedistrictforpossiblepublicationintheformofinterviews,video,orphotographsrelatedtoprogramsor eventsinwhichmychildmaybeparticipatingatschool.
(Signatureofparent/guardian)
Military Opt-out
Federallawrequiresschooldistrictstoreleasethenames,addresses,andtelephonelistingsofsecondaryschoolstudentstomilitary recruitersupontheirrequestunlessthestudentsortheirparentsrequestthatthestudents’ contactinformationnotbereleasedwithout priorwrittenparentalconsent. Astheparentorlegalguardianofthisstudent,Iamexercisingmy"opt-out"righttodirectthatthe schooldistrictshallnotreleasethestudent'sname,address,andtelephonelistingtomilitaryrecruiterswithoutmypriorwritten consent.
(Parent/guardiansignature)
CourtOrders:Parent/guardian,pleaserememberthatifaparentorguardianhasevidenceofacourtorderwhichdeniesthenon custodialparent,oranyoneelse,fromhavingaccesstoschoolrecords,fromvisitingthestudentatschool,orfromremovingthe studentfromschool,suchevidenceMUSTbeprovidedtothebuildingadministrator.
PLEASESIGNONLYIFYOUREFUSE
DirectoryInformation
TheFamilyEducationalRightandPrivacyActrequiresthatDMPSdesignatecertainpersonallyidentifiableinformationtakenfrom students’ educationalrecordsas"directoryinformation." Informationdesignatedas"directory informationmaybemadeavailableto thepublicunlessyouastheparent/guardian oreligiblestudentrefusethereleaseofsuchinformation.
TheDesMoinesIndependentCommunitySchoolDistricthasdesignatedthefollowinginformationasdirectoryinformation:Student's name,address,telephonenumber,ande-mailaddress,parent's name,addressandtelephonenumber,dateandplaceofstudent'sbirth,curriculum(majorfieldofstudy),yearinschool,participationinrecognizedorganizations,activitiesandsports,weightandheightof membersofathleticteams,degrees,awardsandhonorsreceived,themostrecenteducationalinstitutionattendedbythestudent,photographsofthestudent,dateofattendanceattheschooldistrict(generalperiodsoftimeduringwhichanindividualattendedorwasenrolledinaneducationalagencyorinstitution).
Asparent/guardianof(student),Irefusethedesignationandreleaseofanyorallcategoriesofpersonally identifiableinformationasdirectoryinformation.
(Signatureofparent/guardian onlyifrefusingthedesignationandrelease ofdirectoryinformation)
Thisformcanalsobefoundonourwebsite