13-GBN 22-23 TCD Student Registration Form

Home School

13-GBN

Additional School - Please leave blank if this does not apply.

To be used only if you attend a school other than the one listed above (example: private school students should note the private school they attend here).

Are you currently a TCD student? (during the 21-22 school year) *

Yes No

Current TCD Program

First Program Choice *

Please visit www.tcdupage.org - Virtual Tours to watch videos about each program.

Second Program Choice *

This program needs to be DIFFERENT from your 1st program choice. Students who do not select a different 2nd program choice may not be registered at TCD if their 1st choice is not available.

The Emergency Medical Technician program requires students to be seniors at the time they are taking this class. A valid social security number is required to take the National Registry of Emergency Medical Technicians exam.

Students in the Emergency Medical Technician program may be required to be fully vaccinated against Covid19 prior to beginning clinicals.

The Medical Assisting program requires students to be seniors at the time they are taking this class. A valid social security number is required to take the IL Registered Medical Assistant exam.

The Cosmetology program requires students to have a valid social security number in order to register for the IL Licensed Cosmetologist exam after completing two years of our program.

A valid social security number is required to take the Illinois Nursing Assistant Certification exam after completing TCD's Nursing Assistant Training Program.

Students in the Nursing Assistant Training Program may be required to be fully vaccinated against Covid19 prior to beginning clinicals.

Student ID *

This is your school ID number

Full Name *

First Name Last Name

Preferred Name

For TCD teacher reference only. Please leave blank if not applicable.

Gender *

Male Female Non Binary Transgender Prefer not to answer

Date of Birth *

Date

Student T-shirt Size *

Used for program and event t-shirts

Student's E-mail Address *

Please use your school email address.

Student's Cell Phone Number *

Area Code Phone Number

Student's Mailing Address *

Full Street Address

Apt / Unit #

City State

Zip Code

Allergies

Please leave blank if not applicable

Medical Condition(s)

Please leave blank if not applicable

Medication(s)

Please leave blank if not applicable

Primary Parent / Guardian

Contact Information

This should be the parent/guardian the student lives with and who should be contacted first in case of an emergency.

Full Name *

First Name Last Name

Relationship to Student: *

Primary Phone Number: *

Area Code Phone Number

Additional Phone Number:

Area Code Phone Number

Parent/Guardian E-mail Address: *

example@example.com

Preferred Language:

This parent/guardian lives with this student: *

Yes No

This parent/guardian has custody of this student: *

Yes No

This parent/guardian is an emergency contact for this student: *

Yes No

This parent/guardian can pick up this student from TCD: *

Yes No

Secondary Parent / Guardian Contact Information

Please leave all fields blank if not applicable.

Secondary P/G Name:

First Name Last Name

Secondary P/G relationship to student:

Does this contact have the same address as the student? (Secondary p/g)

YES NO

Address

Full Street Address

Apt / Unit #

City State

Zip Code

Secondary P/G Primary Phone Number:

Area Code Phone Number

Secondary P/G Additional Phone Number:

Area Code Phone Number

Secondary P/G E-mail Address:

example@example.com

Secondary P/G Preferred Language:

This parent/guardian (2nd) has custody of this student:

Yes No

This parent/guardian (2nd) is an emergency contact for this student:

Yes No

This parent/guardian (2nd) can pick up this student from TCD:

Yes No

Emergency Contacts Information

These contacts should be a local relative/friend who will be responsible for your student should he/she become ill and the parent(s)/guardian(s) listed above cannot be reached.

Please do not list a contact that has already been listed in a parent/guardian field.

Please leave all fields blank if not applicable.

Emergency Contact 1 Name:

First Name Last Name

Emergency Contact 1 relationship to student:

Emergency Contact 1 Phone Number:

Area Code Phone Number

This contact (EC1) can pick up this student from TCD:

Yes No

Emergency Contact 2 Name:

First Name Last Name

Emergency Contact 2 relationship to student:

Emergency Contact 2 Phone Number:

Area Code Phone Number

This contact (EC2) can pick up this student from TCD:

Yes No

Student & Parent/Guardian

Agreements

To be completed as noted in each question.

_________________________________________________________________________

Nondiscrimination Statement: Technology Center of DuPage extends equal opportunity in the areas of admissions, educational programs, activities, and employment without regard to race, color, religion, national origin, ancestry, sex, sexual orientation, marital status, disabled status or age.

_________________________________________________________________

Race / Ethnic Code (for state funding purposes only) *

American Indian or Alaskan Native Asian Black or African American Hispanic Native Hawaiian/Other Pacific Islander White Two or More Decline to Answer

Media Release

I hereby acknowledge and grant permission for representatives of Technology Center of DuPage and its governing body (DuPage Area Occupational Education System or DAOES) to use my student's image, voice, and/or identification information for educational , informational, or promotional purposes. This may include release to the news media, posting on the TCD/DAOES websites or World Wide Web, or use in TCD/DAOES publications, presentations, or displays.

Images may include video recordings, photographs, digital images, negatives, or prints. Voice may include audio-video recordings, quotes, or testimonials. Identification information may include my name, hometown, high school, TCD program, grade level, honors/awards, or activities related to my TCD program.

Parent/Guardian - I grant Media Release *

YES NO

Directory Information Release

The primary purpose of directory information is to allow Technology Center of DuPage to include information from your child's education records in certain publications. This information can include: student name, mailing address, telephone listing, photograph, and/or grade level. The telephone listing will be used ONLY for student follow-up study.

Notice for Directory Information
The Family Educational Rights and Privacy Act (FERPA), a federal law, requires that
Technology Center of DuPage, with certain exceptions, obtain a parent’s/guardian’s
written consent prior to the disclosure of personally identifiable information from your child’s education records. However, Technology Center of DuPage may disclose
appropriately designated “directory information” without written consent, unless you have advised the school to the contrary. The primary purpose of directory information is to allow Technology Center of DuPage to include this type of information from your child’s education records in certain publications.

Parent/Guardian - I grant Directory Release *

YES NO

Internet Acceptable Use Policy Commitment Statement

My signature below, and that of my parent(s) or guardian(s), means that I have read, understand, and agree to follow the guidelines as stated in the TCD Internet Use Policy of the Student/Parent Handbook listed below, which is also available at www.tcdupage.org.

Standard Policies of Student Internet Usage

Students will be given guidance by their instructors on how to use the Internet for educational purposes aligned with the goals of TCD. This is a significant educational opportunity for students, but it also entails a responsibility.

Appropriate Use

The use of the Internet at TCD is restricted to the support of any research for educational purposes directly involved in the execution of class assignments and is consistent with the educational goals of the school. Students will use computing and networking resources in an effective, efficient, ethical, and legal manner.

Security

The school administrators and instructors work to create a secure environment for the use of the Internet. If a problem is discovered on the Internet, it is imperative that the problem be reported directly to the school administration or staff. Access to areas that have been posted as off-limits is forbidden. Any unauthorized use of files is prohibited.

Netiquette

Users are expected to show mutual respect for others at all times. A cooperative attitude will ensure everyone has equal privileges, privacy and protection from interference or harassment. Users will avoid excessive use of resources: for example, computers, printers, graphic devices, networks, and processor time. Students will respect the people responsible for overseeing the computers in the classroom and those responsible for administering the network and follow established procedures.

Student Publishing on the Internet

All efforts will be made to obtain written authorization from a parent/guardian prior to any TCD publication of any student work (text, audio, video, and picture) on the Internet. Although TCD staff will attempt to ensure that names, addresses, and/or other means of identification will not accompany student works published on the Internet, due to the vast and rapidly growing capabilities of computers, TCD cannot guarantee such information will remain private.

Internet Access and Electronic Mail Policy

No Expectation of Privacy

Students should be aware that they have no privacy interest and no reasonable expectation of privacy while using any TCD-provided access to the Internet, including the World Wide Web, and electronic mail (e-mail). In addition, students should have no expectation that any information transmitted or stored on TCD computers is or will remain private.

Monitoring and/or Searching Internet Use and/or Electronic Communications

In the course of their duties, system operators, board personnel, or other staff may monitor and/or search individual use of the Internet or review the contents of stored or transmitted data.

All products, information, and files created by a student using TCD technology (either hardware or software) are also subject to such monitoring and/ or searches. Such monitoring and/or searches may occur with or without cause.

A partial list of circumstances that could cause such a monitor or a search is:

a. Ensuring that TCD systems are not used to transmit discriminatory or offensive material or messages (including but not limited to defamatory, false, inaccurate, abusive, threatening, racially offensive, or illegal material).

b. Ensuring that TCD systems are not used to transmit, receive, download, or otherwise produce or view obscene, pornographic, profane, sexually oriented, or illegal material or messages.

c. Determining the presence of illegal material or unlicensed software.

d. Ensuring that TCD systems are not used to conduct illegal activities, engage in gambling, wagering, betting, or selling chances, or otherwise engage in any activity for personal gain or profit.

e. Responding to legal proceedings that call for the production of electronically stored evidence.

f. Responding to investigations of misconduct or wrongdoing.

g. Making purchases on the Internet and/or World Wide Web or selling or offering to sell any goods or services on the Internet or World Wide Web.

h. Any other circumstance in which monitoring and/or a search may or is expected to produce evidence of misconduct or wrongdoing.

Violation of Policy

Violation of this policy and/or any misuse of TCD technology may result in limiting or revoking personal Internet use privileges, including access to the World Wide Web and/or electronic mail, suspension/expulsion from school, and/or other appropriate disciplinary action for students.

Student - I Agree to the Internet Acceptable Use Policy *

YES NO

By selecting "NO", you decline the privilege to use Internet resources and will not be allowed its use during TCD, including TCD Public WiFi.

Student - I have reviewed the Student / Parent Handbook on the TCD website (www.tcdupage.org) *

Yes No

As a TCD Student you will still be bound by rules and regulations contained in the Student / Parent Handbook. It is recommended you take time to review the Student / Parent Handbook.

Parent/Guardian - I have reviewed the Student / Parent Handbook on the TCD website (www.tcdupage.org) *

Yes No

How did you hear about TCD? Please check all that apply.

Parent/Guardian Electronic Signature

The electronic signature and all of its related fields replace a handwritten signature on paper and is legally binding.

Parent/Guardian - I affirm that the information provided is true, correct, and complete to the best of my knowledge and belief. This electronic signature as its related fields are treated like a handwritten signature on a paper form. *

Parent/guardian - please type your name in the box above as your electronic signature.

Token Verification - Counselor Only

Counselors: Use your assigned token/keyword to edit the entries.

2022-2023

Student Demographics

Student Medical Information

Parent / Guardian Contact Information

2022-2023

Counselor Section Only