(Hispanic/Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American or Spanish culture of origin, regardless of race.)
* Only choose Mother & Stepfather or Father &Stepmother if BOTH the parent and the stepparent have legal custody of the student and documentation can be provided.
We have read and understand all of the information contained in the Parent/Student Handbook. By signing below, I/we agree to abide by and support the Cliff Park High School rules and regulations, including the Code of Conduct and all other policies, as outlined in the Parent/Student Handbook. Although the Parent/Student Handbook reflects the current policies of Cliff Park High School, it may be necessary to make changes from time to time to best serve the needs of our school and students.
Purpose - To enable parents and guardians to authorize the provision of emergency treatment for their child who becomes ill or injured while under the school's authority when parents or guardian cannot be reached.
Residential Parent or Guardian
PART 1 OR PART 2 MUST BE COMPLETED
Part 1 - Grant Permission
I hearby give consent for the following medical care providers and local hospital to be called.
In the event reasonable attempts to contact me have been unsuccessful I hereby give my consent for (1) the admission of any treatment deemed necessary by above named doctor; or 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 sunless the medical options of two other licensed physicians or dentists concur 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:
Part 2 - 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 Liberty High School authorities to take the following actions:
Parents and Guardians: A completed language usage survey is required for all students upon enrollment in Ohio schools. This information will tell school staff if they need to check your child’s proficiency in English. Answers to these questions ensure your child receives the education services to succeed in school. The information is not used to identify immigration status.
Indicate your language preference so we can provide an interpreter or translated documents at no cost when you need them. All parents have the right to information about their child’s education in a language they understand.
Language BackgroundInformation about your child’s language background helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.
Prior EducationResponses about your child’s birth country and previous education give us information about the knowledge and skills your child is bringing to school and may enable the school to receive additional funding to support your child.
Thank you for providing the information above. Contact your school or district office if you have questions about this form or about services available at your child’s school. Translated information about schools’ civil rights obligations to English learner students and limited English proficient parents can be found here: https://www2.ed.gov/about/offices/list/ocr/ellresources.html
TO BE COMPLETED BY PARENT, GUARDIAN OR ADULT STUDENT (Please print clearly):
School: Liberty High School Location: Dayton, OH 45402
I/we understand that as part of my/our child’s attendance at Liberty High School (“School”), photos, videos, and quotations may be taken for use in publications and reports about the program. I/we further understand that members of the news media invited to cover the program may take photos, videos and quotations. I/we grant permission to the School and its Board of Directors, Management Company, employees, agents and representatives to use such materials for the promotion of the program and to use this student’s name, photographic likeness, alone or in a group, in any publication, document, TV production,video or to release said name or likeness to any media outlets including, but not limited to, newspapers, magazines or TV stations for publicity and/or recognition purposes and/or to use this student’s name and/or photographic likeness, alone or in a group, on the official website of the School and/orManagement Company. I agree that I and/or my child shall have no right, title, or interests in any photo or videotape covered by this agreement and waive any right to compensation for such use. I release the School, its Board of Directors, the Management Company, employees, agents, representatives and all organizations andindividuals related to the School from any and all liabilities or damages that result from the use of this student’s name and/or photographic likeness as described above.
The Family and Educational Rights and Privacy Act (FERPA) provides parents and students over 18 years of age ("eligible students") certain rights regarding the student’s educational records. In order to serve the student's educational needs, Liberty High School may find it necessary to disclose a student's name and address to a vendor to provide them with the appropriate learning solutions. These vendors agree to the confidentiality of the student's name and address and will not use such information for any purpose other than those required under their vendor contract with Liberty High School. I hereby agree that my student's name and address may be provided to these entities to ensure that Liberty High School can best meet the educational needs of my student.
Confidentiality and Communication Consent:
As the parent/guardian, I agree to allow Liberty High School personnel the right to contact me or my student in any manner of communication that pertains to the student's academic well-being. This may include, but is not limited to: Director, Assistant Directors, Teachers, Family Advocate, Employability Specialists, Administrative Assistants, and EMIS/Student Data Specialists. This information will remain confidential except in cases where there is an ethical and or legal responsibility to limit the above said confidentiality.
As a Student at Liberty High School, you will be participating in a Career Based Intervention Program. This Program allows the Student to earn high school credits for time spent at work. In order to receive the appropriate amount of credits for work, the Student must regularly provide the School with employment information including but not limited to the name and address of the employer, the amount of time worked per pay period, the date of termination/last date worked, and efforts made to obtain new or previous employment. Failure to provide appropriate documentation will prevent the Student from earning the corresponding credits. All Students are required to complete all regular academic coursework. Additionally, Students under the age of 18 must have a valid work permit.
STUDENT AND PARENT CONTRACT FOR CAREER BASED INTERVENTION
The Career Based Intervention (CBI) Program is designed to give students the opportunity to complete their education while learning the obligations of the world of work. The success of students in the CBI Program is dependent upon their desire to improve. There are definite responsibilities the STUDENT must agree to carry out before being enrolled:
As a condition of enrollment into the Liberty High School Career Based Intervention Program, I, First Name Last Name ,agree to the following conditions:
The Liberty High School's Career Based Intervention Program affords the Student the ability to attend school for a shorter time period each day than the required four and one-half hour session. ONLY STUDENTS WHO ARE REGULARLY WORKING MAY TAKE ADVANTAGE OF THIS PRIVILEGE. IF A STUDENT IS NOT REGULARLY WORKING, THE STUDENT MUST ATTEND THE FULL 4.5 HOUR SESSION.
By signing below the Student acknowledges that s/he will be participating in the Liberty High School's Career Based Intervention Program, and that s/he will comply with the rules and regulations of the Program.
I, First Name Last Name , the Parent/Guardian fully understand and agree with the goals, program requirements, and rules of the Liberty High School's Career Based Intervention Program. I will fully cooperate with the school to accomplish the goals and to ensure that the requirements are met and the rules are adhered to by my Student. I give my permission for my Student, to participate in the Career Based Intervention Program at this school.
What is a “school-parent compact?
Each Title I, Part A School must jointly develop, with the parents of children served under Title I, Part A, a school-parent compact as a component of its written parental involvement policy. A school-parent compact is a written agreement between the school and the parents of children participating in Title I, Part A programs that identifies the activities that the parents, the entire school staff, and the students will undertake to share the responsibility for improved student academic achievement, in addition, the school-parent compact outlines the activities that the parents, school staff, and students will undertake to build and develop a partnership to help the children achieve to the State’s high academic standards.
What information and opportunities must schools provide parents of children participating in Title I, Part A programs?
Schools served under Title I, Part A must provide to parents of participating children, in a timely manner, information about the programs, funded by Title I, Part A. That information must include:• A description and explanation of the school’s curriculum;• Information on the forms of academic assessment used to measure student progress; and • Information on the proficiency levels students are expected to meet. Upon the request of parents, schools must provide the opportunities for regular meetings for parents to formulate suggestions and to participate, as appropriate, in decisions about the education of their children. The school must respond to any suggestions as soon as practicably possible. The School, the students, and the parents of the minor students participating in activities, services, and programs funded byTitle I, Part A of the Elementary and Secondary Education Act (ESEA), agree that this compact outlines how the parents, the entire school staff, and the students will share the responsibility for improved student academic achievement and the means by which the school and parents will build and develop a partnership that will help children achieve the State’s high standards. This school-parent compact is in effect during the 2021-2022 school year. The purpose of this Compact, found in Section 118 of Public Law 103-382, is to build and foster development of the school-student partnership to help all students achieve the State of Ohio’s high standards. Parent/Guardians, students, and teachers will share the responsibility for improved student achievement.Each student is responsible for his or her own academic progress in mastering the necessary skills in order to complete the academic program at Liberty High School. • The school will provide high-quality curriculum and instruction in a supportive and effective environment that enables all students to meet the State’s student performance standards. • The school will provide students and parents of minor children with reports on their children’s progress. • The school will provide parents with opportunities to volunteer, observe, and participate in their child’s learning.
• The school will provide reasonable access to staff through parent/teacher conferences and consultations.
Communication between the Student and the School staff is important. As a student who has responsibility for his or her own education, I will attend the daily sessions on a regular basis and do all that is asked of me at the School to the best of my abilities. I, First Name Last Name , agree to Title I service for myself and that I will be responsible for supporting my learning in the following ways:
FAMILY REPRESENTATIVE AGREEMENT Communication between the home and the School staff is important. As a parent or adult who has responsibility for the above-named student, I will attend at least one parent/teacher conference during which this Compact will be discussed as it relates to my child’s achievement. I will read each progress report and talk to my child about the progress report. I understand that I will have reasonable access to my child’s teachers, and will be able to observe classroom activities. I, First Name Last Name , agree to Title I service for my child and that I will be responsible for supporting learning of my child in the following ways:
Your permission is requested for your child to participate in individual advising sessions and group activities. This time will be used to discuss ideas, behaviors, feelings, attitudes, and opinions of the student. Because advising is based on a trusting relationship between the Advocate and the student, the FES Advocate will keep the information shared in the sessions confidential except in certain situations in which there are an ethical and/or legal responsibility to limit confidentiality. In the following circumstances you will be notified.
1. If the child reveals information about hurting himself/herself or another person.
2. If the child reveals information about child abuse.
3. Other situations that ethically and/or legally compel disclosure.
By signing this form I give my informed consent for my child to participate in individual advising sessions and group activities. I understand that
1. This time will be utilized to strengthen interpersonal skills, discuss feelings, share idea, practice new behaviors, and build self-esteem.
2. Anything that is shared during this time will be kept confidential by the Family Advocate except in the above-mentioned cases.
You are authorized to release the following records for:
OHIO REVISED CODE OHIO STATUTE 3319.321 Text of Statute: Nothing shall prevent the transfer of a student's record (this includes transcripts and IEP's) to an educational institution for a legitimate educational purpose. A parent, legal guardian or a person 18 years or older can request transcripts upon withdrawal from one public school district for the purpose of attending another school. This is a State Law and must be followed. Please return requested records to address listed below: Address:
Liberty High School Fax: (937) 795-1123140 N. Keowee St. Email: firstname.lastname@example.orgDayton, OH 45402 Attn: Student Registrar