The Pathways Schools ~ 2025-2026 Student Information and Consent Forms

Student Information
Section 1/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Name of person completing this form:*

First NameLast Name
Email address of the person completing this form (this email will receive a link to return and complete your form)*
example@example.com
Student Information
Pathways School (select location):*
Full Name*

First NameMiddle NameLast Name
Date of birth*
Last 4 Digits of SS#:
Current Grade:
Address*

Street Address

Street Address Line 2

CityState / Province

City, State, and Postal / Zip Code
City, State, and Postal / Zip Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Home County/District:

Parent/Guardian Information
Section 2/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent/Guardian # 1 Name*

First NameLast Name
Parent/ Guardian # 1 relationship
Parent/Guardian # 1 Address*

Full Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian # 1 Phone Number

#1 Cell Phone#1 Home Phone#1 Work Phone
Parent/Guardian # 1 Email
example@example.com
Parent/Guardian # 2

Full NameRelationship
Parent/Guardian # 2 Phone Number

#2 Cell Phone#2 Home Phone#2 Work Phone
Parent/Guardian # 2 Email
example@example.com
**In case of an emergency and a parent/guardian cannot be contacted, please identify 2 people the school may contact:**
Emergency Contact # 1 *

Full NameRelationshipPhone
Emergency Contact # 2

Full NameRelationshipPhone

Race and Ethnicity Identification
Section 3/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
Date*

MonthDayYear
Date
The federal government, which requires all states to collect information, has developed a way to report ethnicity and race that includes categories. These categories provide a more accurate picture of the nation’s ethnic and racial diversity. It also enables individuals to be identified in ethnic and racial classifications and in more than one racial category. These categories are for use in state and federal data collections that include data on ethnicity and race
Ethnicity Designation
Is the student HISPANIC OR LATINO? Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, are considered Hispanic or Latino*

YesNo
Race Designation

Read the descriptions below and check the box or boxes that indicate this student’s race. You must select at least one race, regardless of ethnicity designation. More than one response can be selected.
Indicate the student's race (Select all that apply)*

AMERICAN INDIAN OR ALASKAN NATIVE: A person having origins in any of the original peoples of North or South America (including Central America), and who maintains a tribal affiliation or community attachment.ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.BLACK OR AFRICAN AMERICAN: A person having origins in any of the black racial groups of Africa.WHITE: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Parent/guardian initials:*

Medical
Section 4/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
Date*

MonthDayYear
Date
Doctor or HMO's information

Provider's NamePhone Number
Address

Full Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your son/daughter have health insurance?

YesNo
If yes, Medical Assistance?

YesNo
Medical Insurance Company

Insurance's NamePolicy #
Please list allergies or other special medical conditions:

Street Address Line 2

CityState / Province

Postal / Zip Code
** NOTE If student takes any medications, please complete the Medication Forms available at
https://pathwayschools.org/wp-content/uploads/2019/06/1_MedicationForm.pdf
School officials may administer first aid and/or take your child to the nearest appropriate medical facility in the event of a medical emergency. IMPORTANT NOTE: Emergency personnel will be contacted and used, as deemed necessary, in emergency situations.*

YesNo
Parent/guardian initials:*

Transition Services (3 of 3 pages)
Section 5/11
PART 4: By signing this consent form, I understand that:
- The consent given for Part 1 (Communication) and Part 2 (DORS Referral) are valid for 12 months from the signature date below.
- Part 3 of this form will require a signature for each IEP meeting where an agency representative is requested.
- Activities marked with "Yes" above indicates my permission to allow the action to occur on my child's behalf, throughout the year.
- Activities marked with a "No" above will not be conducted on behalf of my child unless written consent is provided at a later date.
- My consent is voluntary and may be revoked at any time with written notification.
Parent/guardian initials:*

Assessment
Section 6/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
Date*

MonthDayYear
Date
Once my son/daughter is enrolled at The Pathways Schools, I give my permission for the school or contracted personnel to administer assessments. The purpose of these assessments is to update academic skill levels and to identify postsecondary interests and career goals and interests.
This list is not intended to be all inclusive, but rather to give examples of the types of assessments that may be given.

The assessments given may include the following:
- Woodcock-Johnson Psycho-Educational Battery - Tests of Achievement IV
- QRI-6 (Qualitative Reading Inventory)
- Informal Assessments: Mathematics Assessments 6-8, Mathematics Assessment 9-12, Classroom Mathematics Inventory K-6, For the Teacher on the Go.....(reading and writing)
- Transition Assessments
- Functional Behavior Assessment (FBA)/Behavior Intervention Plan (BIP)
I understand that I may receive the results of the above or any other testing and have those explained to me. I also understand that all testing results will be treated with confidentiality. Only the parents/legal guardians, LSS and school staff who work with or provide services to the student are permitted access to this information unless I give my permission in writing.*

YesNo
Parent/guardian initials:*

Transportation
Section 8/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
Date*

MonthDayYear
Date
PERMISSION FOR SCHOOL TRANSPORTATION DURING THE SCHOOL DAY

This permission shall be in effect the date of signature and shall extend for the duration of the 2025-2026 school year and ESY 2026, unless revoked in writing at any time.

I give my permission to The Pathways Schools, or person(s) operating on its authorized behalf, to have my son/daughter, participate in and be transported for activities, such as, but not limited to:
- community-based educational experiences and
- transition experiences, including job exploration, visits to vocational training sites, job shadowing experiences, volunteer and paid work, or internships.
I understand that at any time transportation may be provided:
- by a staff member with or without another staff member and my child
- by a staff member with or without another student
- in a staff member's vehicle; or
- in a Pathways vehicle.
YesNoOther
If "no" or "other", please explain:

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/guardian initials:*

Telehealth and Distance Learning (1 of 2 pages)
Section 9/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
Date*

MonthDayYear
Date
Introduction

Distance learning and telehealth involve the use of electronic communications to enable educators and related service practitioners to provide services for the purpose of IEP implementation. The information exchanged and obtained through distance learning and telehealth may be used for diagnosis, therapy, follow-up and/or education, and may include all of the following:
- Student records
- Medical records and images
- Live two-way audio and/or video
- Output data from sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of student identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits
- Improved access to services by enabling a student to remain in his/her home (or at a remote site) to receive IEP prescribed services from a healthcare practitioner at a distance/other site(s).
- Continuation of IEP prescribed services.
Possible Risks

As with any service, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
- Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate decision making by a practitioner;
- Delays in service could occur due to deficiencies or failures of the equipment and technology;
- In rare instances, security protocols could fail, causing a breach of privacy of personal identifiable information

Telehealth and Distance Learning (2 of 2 pages)
Section 9/11
By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of student information also apply to distance learning and telehealth, and that no information obtained in the use of distance learning or telehealth, which identifies the student, will be disclosed to researchers or other entities without my consent.

2. I understand that the student/parent has the right to withhold or withdraw consent to the use of distance learning or telehealth in the course of service provision at any time, without affecting the student's right to future service or treatment.

3. I understand that the student/parent has the right to inspect all information obtained and recorded in the course of a distance learning or telehealth interaction, and may receive copies of this information.

4. I understand that a variety of alternative methods of service provisions may be available, and that the student/parent may choose one or more of these at any time. The practitioner can explain the alternatives to the student's/parent’s satisfaction.

5. I understand that distance learning and telehealth may involve electronic communication of personal identifiable information (PII) to other service practitioners who may be located in other areas, including out of state.

6. I understand that the student/parent may expect the anticipated benefits from the use of distance learning or telehealth, but that results cannot be guaranteed or assured.

Student/Parent Consent to the Use of Distance Learning and Telehealth (select one)
GIVE INFORMED CONSENT - I have read and understand the information provided above regarding telehealth, have discussed it with the practitioner(s) or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give informed consent for the use of telehealth for the continuous implementation of the student's IEP.DO NOT GIVE INFORMED CONSENT - I have read and understand the information provided above regarding telehealth, have discussed it with the practitioner(s) or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby Do Not give informed consent for the use of telehealth for the continuous implementation of the student's IEP.
Parent/guardian initials:*

THE PATHWAYS SCHOOLS PARENT HANDBOOK
Section 10/11
The Pathways Schools ~ 2025-2026 Student Information and Consent Forms
Student's Name*

First NameLast Name
I understand The Pathways Schools Student/Parent Handbook and site-specific handbooks are available on The Pathways Schools website at www.pathwayschools.org

I understand that the techniques and disciplinary actions for managing inappropriate behavior described in The Pathways Schools Parent Handbook include general separation, student requested time-out, staff directed time-out, lunch detention, community/school service, in-school intervention, search and seizure, suspension, alternative placement, and termination or expulsion. The Pathways Schools does not utilize physical restraint, exclusion or seclusion.
YesNo
Typing my name here acknowledges that all of the information and consents included in these forms are accurate to the best of my knowledge.
Type full first and last name*
Date*

MonthDayYear
Date
Should be Empty: