Student Record Release Permission
Nashville After Zone Alliance (NAZA) partner agency, DYMON in the Rough, receives information from Metro Nashville Public Schools (MNPS) about the students that are enrolled in NAZA-funded or affiliated programs. The programs utilize personally identifiable information (PII) from students' school records to plan and provide high-quality after-school programming for your student. Information that is deemed as part of the student's school record is listed below:
- School ID
- School name
- Student number
- Last name
- First name
- Middle name
- Preferred name
- Birthdate
- Gender
- Grade level
- IEP Status
The information will be treated as confidential in agreement with the Family Educational Rights and Privacy Act (FERPA), will not be released to any other parties that are neither associated nor affiliated with NAZA, and will be used for the sole purposes to continue providing high quality after school programming to your child. NAZA personnel and DYMON in the Rough will be properly trained to protect your student's Personally Identifiable Information (PII Any PII that has been collected and maintained by Backfield in Motion will be permanently destroyed at the end of the academic year.
I give my permission to the Nashville After Zone Alliance and DYMON in the Rough, unless otherwise noted in the space below:
a. To have my child participate in NAZA-funded programs and activities at my child's school as well as other off-site locations throughout the NAZA system, as specified in this enrollment form, knowing that this might include special activities, such as off-site events, end-of-year celebrations, homework/academic help, and field trips, and realizing that some of these may take place outside of regular program hours.
b. With the medical information provided in the program application in mind, engage in all activities except as noted.
c. To secure proper medical treatment for my child in the event of an emergency. If I or my emergency contact cannot be reached, I give permission for a physician to order routine tests and treatment for the health of my child. I give permission to a physician to secure treatment and/or hospitalize my child; after all emergency, contact attempts have been made.
d. To provide assistance in accessing devices and internet services when presented as a barrier for my child to participate in afterschool and summer programs.
e. To use in media releases to benefit NAZA and its funded providers, photographs, creative work, quotes, videos, or other media which may include my child.
I, the undersigned, understand, acknowledge, and agree:
*That I have read and understand the information provided in the Parent Consent Form.
*That I will update any information I provided about my student in a timely fashion.
*That DYMON will request my child's records that may contain personal information (share demographics, grades, assessment, attendance, behavior/suspensions, IEPs, and information about access to technology and the internet at home) for the sole purpose of helping my child succeed in school and beyond.
*I, therefore, waive, with respect to these disclosures, any duty of confidentiality arising from Federal or State requirements. That participation in NAZA-funded programs and providing information about my child may involve certain risks. I assume all of these risks.
*That DYMON will make themselves available to children, parents, and school staff and any concerns they might have.
*That DYMON will protect the safety, interests, and rights of all individuals in the program. Therefore, each program will provide a parent/youth handbook or other program-specific information, including behavior policies and grievance procedures.
*That my child may be asked to complete surveys regarding the program for evaluation purposes.
*That I will not seek to hold NAZA or its funded providers responsible for any losses or damages whatsoever which I or my child may incur in connection with NAZA or its funded providers.
*That all program staff are employed by DYMON, who are responsible for the operations of the program and supervision of their personnel. NAZA takes no responsibility for these operations or supervision.
I, the parent or legal guardian, give consent for Metro Nashville Public Schools to share my child's information, as described above, with NAZA staff and its funded and affiliated partners for the purpose of planning and providing high-quality afterschool programming to my child. I fully release and discharge MNPS and its employees from any and all liabilities arising out of or in connection with the above-described data sharing relative to NAZA and NAZA partners. I reserve the right to withdraw my consent at any time by submitting a written notice of withdrawal of consent to NAZA or its partner.