Madison County Schools Transportation Verification Form

22-23 Back to School Student Update
Parent/Guardian:

The following forms need to be updated for every student at the beginning of each school year. Complete this packet if your student was enrolled in a Madison County School on the last day of the previous school year (May 26, 2022).

If your student was not enrolled in a Madison County School on the last day of the previous school year, please exit this packet and return to the Madison County Schools website and complete the Student Enrollment Forms pack.

(Parent/Guardian: Please note-throughout this update process entering your name in a Parent/Guardian Signature field is considered the equivalent of a handwritten signature)
Student Information:
(1)School student is enrolled in: *
(3)Student First Name *
(2)Student Last Name *
(4)Student Date of Birth *

Month Day Year
Date
Grade *

Madison County Schools Transportation Verification Form
Each year at the beginning of school and again in January, the school is required to verify the transportation code for each student. Please verify the correct code for your child and return the completed form to the school office as soon as possible. If not completed by the student or parent/guardian, then a school official (teacher, clerk or other) may interview the student and complete this form for correct data entry.

The following is an explanation of transportation codes:

NT= students who are NOT transported by the Madison County School System

T1= students who are transported by the Madison County School System OVER 1 mile to and from school

T2= students who are transported by the Madison County School System UNDER 1 mile to and from school T3= students who are transported by Madison County School System OVER 1 mile only ONCE daily

T4= students who are transported by the Madison County School System UNDER 1 mile only ONCE daily

T5= students who are approved for special transportation accommodations (documentation required in student's IEP)

If your child’s transportation changes from day to day, please check the code which your child uses
(3) Student First Name *
(2) Student Last Name *
(7) Street Address *
(8) City *
(9) Zip Code *
Mailing Address if different from above
Parent Guardian Home Phone
Parent Guardian Cell Phone
Please choose only one: *

NT T1 T2 T3 T4 T5
Madison County Schools is committed to nondiscrimination on the basis of race, color, national origin, age, religion, marital status, sex or disability in educational programs, activities and employment as set forth in compliance with federal and state guidelines. Responsibility for coordination of compliance efforts and receipt of inquiries concerning the guidelines above may contact the Director of Human Resources, Madison County Schools 301 Highland Park Dr., Richmond, KY

REGULATIONS FOR PUPILS RIDING MADISON COUNTY SCHOOL BUSES
THE PRIVILEGE OF ANY PUPIL TO RIDE A SCHOOL BUS IS CONDITIONED UPON THEIR GOOD BEHAVIOR AND OBSERVANCE OF THE FOLLOWING RULES AND REGULATIONS. ANY PUPIL WHO VIOLATES ANY OF THESE RULES OR REGULATIONS WILL BE REPORTED TO THE PRINCIPAL OF THE SCHOOL WHICH THE PUPIL ATTENDS FOR NECESSARY CORRECTIVE ACTION.

1.  The driver is in full charge of the bus and the pupils. Pupils shall obey the driver courteously and promptly.

2.  Pupils shall occupy the space designated for them by the driver.

3.  Pupils shall be on time, the bus cannot wait for those who are not on time.

4.  Pupils are never to stand in the road while waiting for the bus.

5.  Pupils are to clean their feet before entering the bus.

6.  Pupils shall not spit on the bus.

7.  Pupils are not to throw waste paper or rubbish on the floor of the bus.

8.  Pupils are not to mar or otherwise deface the bus.

9.  Pupils are not allowed to carry a knife or any sharp instrument on the bus. If done the driver will take the knife or instrument to the principal’s office.

10.  Pupils are not to start to school when sick or when any member of the family has a contagious disease.

11.  The following activities are prohibited at all times:

a.Improper behavior to include: insolence, disobedience, vulgarity, foul language, fighting, pushing, shoving and similar offensive acts.

b.The use of tobacco in any form (smoking, chewing, dipping, snuff)

c. Eating or drinking on the bus

d. Throwing articles or objects in or from the bus.

e. Tampering with mechanical equipment, accessories or controls of the bus.

f. Placing musical instruments or other articles at the door by the driiver.

g. Obstructing the aisle in any manner.

h. Occupying more space in a seat than required.

i. Opening or closing windows without permission of driver

j. Toys, electronic games, radios

12.  Pupils are to avoid unnecessary conversations with the driver

13.  Pupils at all times are to keep arms and head inside the bus windows.

14. Pupils are not to leave the bus without the driver’s consent except at home or at school.

15. Pupils are not to leave their seats unless getting on or off the bus unless authorized by the driver.

16. Pupils are to respect persons whom they pass on the routes.

17. Pupils are to report to the driver at once any damages to the bus.

18. Pupils are to walk on the left side of the road, facing the bus and not behind it.

19. Pupils who must cross the road after alighting from the school bus shall pass in front of the bus and not behind it.

20. The driver shall see that the way is clear before the child is permitted to cross the road.

21. Should the conduct of a pupil on the bus endanger the lives or morals of other people, and offending pupils to cease such conduct when requested by the driver to do so, it shall be the duty of the driver to put the offender off the bus and report his action to the principal immediately. This should be done only in extreme cases and as a last resort to protect the Principal, Superintendent or Director of Transportation.

22. Any pupil who violates any of these rules and regulations may be reported to the principal of the school he or she attends for disciplinary action.

PARENTS & GUARDIANS: KEEP THESE REGULATIONS DURING THE TIME THE STUDENTS ARE IN SCHOOL.

WARNING: CLOTHING DRAWSTRINGS AND STRAPS OF ANY KIND CAN BE DANGEROUS AND MAY HANG IN SCHOOL BUS DOORS AND HANDRAILS. REMOVE, SHORTEN OR REPLACE WITH A SAFE TYPE OF FASTENER. PLEASE SIGN BELOW AND RETURN TO THE PRINCIPAL OF THE SCHOOL YOUR CHILD ATTENDS IN ORDER FOR YOUR CHILD TO CONTINUE RIDING THE SCHOOL BUS.
For Middle School and High School Students Only:
I have read and understand the REGULATIONS FOR PUPILS RIDING SCHOOL BUSES and agree, as a passenger, to abide by said regulations.

Clear
(5)Grade *
For the Parent or Guardian:
I have read and understand the REGULATIONS FOR PUPILS RIDING SCHOOL BUSES and agree, as a passenger to abide by said regulations.
(12)Parent/Guardian First Name *
(13)Parent/Guardian Last Name *
Signature *

Clear
(3)Student First Name *
(2) Student Last Name *

Publication Form for Photos,Videos, Interview and Web Publication

09.14 AP.251

PERMISSION FOR MEDIA USE, DISTRICT BROADCAST,WEB OR OTHER PUBLICATION OF STUDENT’S PHOTOGRAPH, LIKENESS, AND/OR VOICE

Throughout the year, there may be in-school programs, events, assemblies, PTA/PTO events that are open to the public and where large group photographs or videos will be taken by the media and/or school/district staff.

In addition, to the above situations, there may be times the media (newspaper, television, or radio), school district staff, or students (as part of class projects and activities) may take photographs, audio/videotape students, or interview students individually. The school district may display student pictures and projects in a variety of ways that reasonably portray programs of the Madison County Schools, including pictures of field trips, science fairs, sports events, and other activities appearing in yearbooks or school/district publications. Student likeness and work may also appear on the district website, thereby making it available to the public.

The school district assumes no responsibility for photographs, audio/videotapes, etc. that may be made by parents or other non-school personnel at public events.
Directions: Check one option below: *

I GIVE permission for my child to be photographed, audio/videotaped, or interviewed. I understand that this permission covers all academic, sporting, and school events/activities as related to the Madison County Schools. I DO NOT GIVE permission for my child to be photographed, audio/videotaped, or interviewed, and understand that this may prevent awards and recognition programs from including my child.
(3)Student First Name *
(2)Student Last Name *
Date

Month Day Year
Date
School: *
(12)Parent/Guardian First Name *
(13)Parent/Guardian Last Name *
Parent/Guardian Signature *

Clear
Once signed and dated, this form shall remain in effect throughout the student’s attendance in the building in which his/her grade level is housed and kept on file by the Principal or School Technology Coordinator. However, at any time during the school year, you may amend this form only by notifying the Principal in writing of your request.

Review/Revised:10/21/2021

Kentucky Parental Notice for One Time Consent to Allow the School District to Access Kentucky Medicaid Benefits
School District Name: Madison County Schools

School/District Contact:Jackie Mahaffey/859-625-6044

The purpose of this letter is to ask for your permission to release information needed to recover costs from Medicaid for eligible school-based services. Local education agencies in Kentucky have been approved to receive partial reimbursement from Kentucky’s Department for Medicaid Services (DMS) for the costs of certain health-related services provided by the district to your child (or children

With your permission, the school district will be able to seek partial reimbursement for medically necessary services to Medicaid recipients in accordance with an Individualized Education Program (IEP), an Individual Family Service Plan (IFSP), or are otherwise medically necessary.

The school district will need to share following types of information about your child: name, date of birth; gender; social security number, Individual Education Plan, Service records and any relevant information. Each year, the district will provide you with notification regarding your permission; you do not need to sign a form every year.

The school district cannot share information about your child without your permission. When you give permission, please be advised of the following:

1.This will allow the release of information, for the sole purpose of billing Medicaid services or auditing, to the following agencies: DMS, Kentucky Department of Education (KDE), Kentucky Department for Public Health, Centers for Medicare and Medicaid Services (CMS), any agency commissioned to audit this program and contractual third-party billing agents.

2.The school district cannot require you to pay anything towards the cost of your child’s health-related and/or special education services.

3.This will not affect your child’s available lifetime coverage or other Medicaid benefit; nor will it in any way limit your own family’s use of benefits outside of school. This will not affect your child’s special education services or IEP rights.; and it will not lead to any risk of losing eligibility for other Medicaid or DMS funded programs.

4.You have the right to change your mind and withdraw your permission at any time.
I give permission to the school district to share with DMS information concerning my child(ren) and their health-related services, as necessary. I understand that this will help our school seek partial reimbursement of DMS covered services.

Clear
Date

Month Day Year
Date
Type your name below:
(3)Student First Name *
(2)Student Last Name *
(4)Student Date of Birth *

Month Day Year
Date
Medicaid Number

Student Directory Information Notification

09.14 AP.12
Date

Month Day Year
Date
Consistent with the Family Educational Rights and Privacy Act (FERPA), parents (or students 18 or older) may direct the District not to disclose directory information listed below. We are required to disclose a student’s name, address, and telephone number if listed at the request of Armed Forces recruiters and institutions of higher education, unless a parent or student who has reached age 18, requests that this information not be disclosed. Information about the living situation of a homeless student is not considered directory information.

Dear Parent/Eligible Student,

This letter informs you of your right to direct the District to withhold release of student directory information for students in the Madison County School District. Following is a list of items that the District considers student directory information. If you wish information to be withheld, please contact the school principal in writing specifying which directory information should not be released. The right to opt-out of directory information changes from parent to student upon the student;s eighteenth (18) birthday. Please be advised that parents cannot prevent the school from using directory information on District-issued ID cards or badges.

If we receive no response within thirty (30) days of the date of this letter, all student directory information will be subject to release without your consent. If you return a letter within the first thirty (30) days, we will withhold the directory information consistent with your written directions, unless disclosure is otherwise required or permitted by law. Once there has been an opt-out of directory information disclosure, the District will continue to honor that opt-out until the parent or the eligible student rescinds it, even after the student is no longer in attendance.

Directory information released to Third Parties other than Armed Forces Recruiters and Institutions of Higher Education

·         Student’s name

·         Student’s major field of study

·         Information about the student’s participation in officially recognized activities and sports

·         Student’s weight and height (if a member of an athletic team)

·         Student’s projected graduation date

·         Degrees, honors and awards the student has received

·         Student’s photograph/picture

·         Most recent educational institution attended by the student

·         Grade level

Armed Forces Recruiters & Institutions of Higher Education

(Parent or student who has reached age 18 may direct the District to withhold information in this section.)

·         Student’s name

·         Student’s address

·         Student phone number

Sincerely,

School Principal

Review/Revised:4/14/2022
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Should be Empty:

22-23 Back to School Student Update

Student Information:

Madison County Schools Transportation Verification Form

REGULATIONS FOR PUPILS RIDING MADISON COUNTY SCHOOL BUSES

For Middle School and High School Students Only:

For the Parent or Guardian:

Kentucky Parental Notice for One Time Consent to Allow the School District to Access Kentucky Medicaid Benefits

Student Directory Information Notification

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