Vanguard Academy Packet ref# RP.03 Student Information Packet Page 1 of 5

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1 Student Information Packet Page 1 of 5 Student Health Evaluation RP Please initial here if there are no known health problems VISION HEARING ALLERGIES Known eye condition (other than corrective lenses) Known hearing problem Food Wears glasses Worn at all times Uses hearing aid Environmental Wears contacts Worn at all times Has tubes in ears Medicine COMMENTS: Does medication need to be administered during school hours? YES NO If yes, please provide a signed Physician s Authorization for Medication in School notice. STUDENT HAS THE FOLLOWING CONDITIONS: Administer during school hours? Condition Medication prescribed by doctor Dosage YES NO Asthma Epilepsy Fainting Spells Diabetes Heart Condition Migraines Allergies ADHD/ADD Other (Specify) Does student have any other health condition which may result in a classroom emergency? YES NO If yes, please specify Does student have a physical condition which limits participation in: Classroom activity YES NO Explanation: Physical Education YES NO

2 Student Information Packet Page 2 of 5 EMERGENCY PHYSICIAN INFORMATION In the event of an accident, or other emergency, when a parent or guardian is unavailable, I hereby authorize a representative of this school to make arrangements as he/she considers necessary for my child to receive medical/hospital care, including necessary transportation, in accordance with their best judgment. Under such circumstances I further authorize the physician named below to undertake such care and treatment as is considered necessary. In the event said physician is unavailable, I authorize such care and treatment to be performed by a licensed physician or surgeon. I agree to assume all financial costs incurred as a result of the foregoing. Physician Name Address Phone Health Insurance Provider Insurance /ID # Hospital Preference The undersigned hereby agrees to bear all costs incurred as a result of the foregoing: Parent/Guardian Signature Date DENTAL INFORMATION Dentist Name Address Phone Insurance Provider Insurance ID#

3 Student Information Packet Page 3 of 5 Photo/Image Release Photos and videotape footage of Vanguard Academy students involved in various school-related activities are often used as part of the school s community relations program. Photographs/videotape/schoolwork may be used in school publications, video productions, newspapers, CD-ROM, television and on the Vanguard s web page. Please sign and return the form below granting or denying permission for photo/video reproduction by the Vanguard Academy. Restricted: I do not grant permission for Vanguard Academy to reproduce my child s likeness in any form, and will not be in the Yearbook. Limited Usage: I give permission for my child s image to be used within Vanguard Academy setting only. The student s picture and name will be included in the yearbook. (not in the larger community). Unrestricted usage: I give permission for my child to be interviewed, identified, and/or photographed/filmed for use in Vanguard Academy s publications, including, but not limited to, publication via web site or other technological publications, videos, newspapers, radio, or television. Child s Name Grade Parent/Guardian Signature Date

4 Student Computer/Internet Use Agreement Vanguard Academy Packet ref# RP.03 Student Information Packet Page 4 of 5 Internet resources can be valuable for a student s education. School internet access is a privilege which may be authorized as well as withdrawn. Students are expected to be aware of and abide by the following: 1. Student Personal Safety a. Personal contact information may not be entered on internet sites open to Public access. This includes student address, phone numbers, and addresses. 2. Internet Use a. Students may use school internet access, including , only for teacher- directed educational activities. b. Students may use school internet access only when authorized and only when supervised. 3. Prohibited Computer Uses a. Students are strictly prohibited to: i. Access or create files or materials without authorization ii. Access or create offensive, profane, or pornographic files iii. Use internet games, multi-user domains, IRC s or web chat iv. Plagiarize works or violate copyrights or trademarks v. Damage, alter, or modify software or hardware vi. Attempt to bypass computer security 4. Expectation of Privacy a. Students have no expectation of privacy in files, discs, documents, etc., that have been created in, entered in, stored in, downloaded from, or used on school equipment. 5. Disciplinary Action a. Disciplinary actions will be taken to meet the specific concerns related to violations of this agreement (e.g. loss of access to computers, suspensions, law enforcement involvement, etc.) Student Name Grade ( ) If I have the opportunity to use school computer equipment, I will do so subject to the provisions of the Student Computer/Internet Use Agreement. Student Signature Date

5 Student Information Packet Page 5 of 5 Parent and Student Compact PARENT/GUARDIAN RESPONSIBILITIES I want my child to achieve academic success, therefore I will: Follow school attendance and tardy policies and make certain my child attends school regularly and on time. See that my child is well-rested and has a healthy breakfast each day. Set aside a specific time and place for homework and assist as necessary. Attend scheduled SEOP/CCR and Parent/Teacher conferences and communicate regularly with my child s teachers to ensure his/her academic success. Support the school and staff in maintaining proper discipline. Encourage positive attitudes toward school. Volunteer in my child s classroom and other school functions as appropriate. Review information and work sent home and respond as necessary. Parent/Guardian Signature Date STUDENT RESPONSIBILITIES It is important that I learn, therefore I will: Follow school attendance and tardy policies by attending school regularly and on time. Complete assignments and homework. Be prepared for class, bringing homework and supplies to school each day. Work to the best of my ability. Work cooperatively with classmates, teachers and staff. Respect myself, other people, and my school. Follow all school rules. Uphold the student code of conduct. Accept responsibility for my own actions. Help support school spirit and unity and create a learning environment free of distractions, by refraining from bullying, dishonest acts, sluffing, chewing gum on school property, having electronics (ipods, cell phones) during instructional time, or other actions that will hinder the education process for myself and others. I will abide by the dress code. Student Signature Date