Gender Related Name and/or Pronoun

Gender Related Name and/or Pronoun
School:
I (we), the undersigned, authorize that
Legal Name (as stated on birth certificate)

First NameLast Name
be referred to by the following approved name(s):
Preferred First Name(s)
And/or be referred to by the following pronoun(s):
Pronoun (s)

Other
*Please be aware that all official legal documentation (report card/transcript) will list LEGAL name.
Signature of student (if 16 or over):
Date

MonthDayYear
Date
Email of student (if 16 or over):
example@example.com
Parent/Guardian Name

First NameLast Name
Relationship to Student
Signature of parent(s)/guardian(s): (OPTIONAL for students 16 & over)
Date

MonthDayYear
Date
Should be Empty: