Release and Enrollment Form

Release and Enrollment Form

Seneca Nation Department of Education Buffalo Tutoring Program
Student Info: First Name* Last Name* Grade Level* School*
Student Info: First Name Last Name Grade Level School
Student Info: First Name Last Name Grade Level School
Student Info: First Name Last Name Grade Level School
Parent/Guardian Name:*
First Name Last Name
Relationship to Student:*
Relationship to Student
Parent/Guardian Phone Number*
Please enter a valid phone number.
Texting?

YESNO
Parent/Guardian Email
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information*
Name of Emergency Contact
Relationship to Student:*
Relationship of Emergency Contact
Emergency Contact Phone Number:*
Please enter a valid phone number.
Texting?

YESNO
Additional Emergency Contact Information (optional)
Add additional emergency contacts as needed
Student Data, Image, Media, and Work Release:

This form allows for the Seneca Nation Buffalo Tutoring Program to access information necessary to complete a required monthly report by the AASP/JOM Tutors, which includes student progress monitoring (attendance, tardiness, disciplinary data, student schedules, progress notes, report cards). A completed copy of this form will be held in the student academic records held at your child's school. Information obtained by these permissions will only be used for Seneca Nation Education Department use for services rendered. Any and all data collected is protected by FERPA and will not be shared with any persons not employed by the Seneca Nation. At any time, a parent/guardian can submit a written letter withdrawing from the Seneca Nation Education Department Buffalo Tutoring Program.*

	I DO give permisison	I DO NOT give permision
Student Work Samples:
Student Data/IEP/Grades:
Student Image/Media:

Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Release and Enrollment Form

Student Data, Image, Media, and Work Release: