Parent or Guardian. Please input your information

Street Address*      City*   State*   Zip*   

Area Code*   Phone Number*   

Your relation to Youth? Mother Father Guardian *   

Child currently lives with? Mother Father Both Guardian *   

Court Order Custody on File? Yes No *   

Check the person(s) to be contacted
Mother   Father   Guardian*      

Alternate Contact
Relation to youth Mother Father Guardian *   

First Name*   Last Name*   

Area Code*   Phone Number*   

Email   

Youth Information  


First Name*   Last Name*   


 Date of Birth*        

 Grade*  

Name of School*   

Tribal Member   D. Lineal   Lineal   Com. Resident*            

I First Name*   Last Name*   , parent/legal guardian of the student named above, hereby give permission and authorization to the Santa Rosa Rancheria Department of Education and authorized staff to do the following:
1.    Have access to make receive copies of my child's academic records including, transcripts, credit audits, testing, grades and applicable special education records (i.e. IEPS).
2.    To discuss and be notified by my child's behavior and disciplinary actions (ex. Expulsion, tickets, referrals).
3.    To allow an SSR employee to attend academic and behavioral meetings pertaining to my child (ex. SST's, IEP, Expulsion).
4.    To disclose any information from my child's academic records to designated representatives of colleges and universities so they may determine my child's eligibility for admission at the institutions, if any need of special services and for general use in planning outreach and recruitment activities.
5.    To allow my child to attend field trips that are sponsored and coordinated by the SRR Department of Education to career information sites, colleges, and universities. I understand that an adult on these trips will supervise my child. Additional signed filed trip permission will continue to be required for each field trip. 
6.    To authorize the Education Department to use my child's name, photographs, quotes in newsletters and press releases. 
7.    To allow authorization to release medical information / records.
8.    To allow authorization to release information/records from Santa Rosa Rancheria Social Service Department.
9.    To have access to online student information for monitoring student’s grades, homework, assignments, and attendance (i.e. Power School, Aeries, etc.).

PLEASE NOTE: This consent must be completed due to tribal policies in regards to tribal student’s academic progress and by being a tribal member of the Santa Rosa Rancheria

By signing this document I hereby filled the form out to the best of my ability and acknowledge that I have received a copy of the SRRERB Academic Policies.

Signature*