Send Records To:
Poplar Schools
PO Box 458
Poplar, MT 59255
Attention: Records, Mariah Dimas

Phone (406)768-6732
Fax: (406)768-6802

I acknowledge notification of this transfer of records are required by the Family Education Rights of Privacy Act of 1974 and understand that I have the right to receive a copy at my own expense, if requested and have an opportunity for a hearing to challenge the contents of the records. I understand that the information transferred will be treated in a confidential manner and will not be transferred to third party without my consent.

Please enclose: Transcripts, Cumulative Folder (or copy of), Immunization
Records, Birth Certificate, Withdrawal Grades, any Special Education Records and
an Attendance Record.

(Please print legibly)

In case of emergency, illness, or accident and the above Parent(s)/Guardian(s) cannot be reached the school is authorized to contact:

I give permission to have my child picked-up or checked-out by the following People: (Please list all individuals in case of emergency, illness, or death.)

**Only a Parent or Guardian may fill out this from.

**Only the people on this list you have authorized will be allowed to pick up your child.

Please inform the office of any changes ASAP.

Montana Office of Public Instruction (OPI)

A change has been made to the reporting of race and ethnicity in educational data to better reflect the country's growing diversity. The change will take place in the 2010-2011 school year and will require all students to be identified using a new two-part race/ethnicity question. The federal government has established the two-part question to recognize Hispanic ethnicity and race as two separate and distinct concepts. Additionally, the change allows the reporting of multiple races (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White).

Identify the ethnicity and race of the individual by answering BOTH questions.

Note: Failure to answer both questions will result in use of prior racial/ ethnic data or an observer identifying for you.

Denise Juneau, Superintendent Montana Office of Public Instruction www.opi.mt.gov

May 18, 2009

Poplar Public Schools needs to determine the Language spoken in the home of each student. This information is essential so that the schools can provide appropriate instruction for all students. We ask your cooperation in helping us comply with this important requirement.

The information contained in this survey is for the use of the school district and the appropriate educational institutions of the state and federal government. It is not public directory information and will not be released as such without written consent from the parent or guardian of the student.

Dear Parent/Guardian:

The Poplar School Nurse will be available to assist your child if he/she needs to take medication at school, to assess minor burns, bruises and scratches and to screen ill children who may need to be sent to their home or to the doctor. In addition, the nurse helps with vision and hearing screening and other health checks. If you would like your child to have these services available during the school day, we need the following information, medical history and permission form signed each school year.

The school nurse will NOT have over the counter medications available (tylenol, pepto-bismol, etc.). If your child is in need of these items you must send or bring it to the nurse with instructions for administration.

OMB Control No. 1810-0021 (Exp. 01/31/2024)

Indian means an individual who is (1) A member of an Indian Tribe or Band, as membership is defined by the Indian Tribe or Band, including any Tribe or Band terminated since 1940, and any Tribe or Band recognized by the State in which the Tribe or Band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.

Write the name of the individual with the tribal membership, if it is not the child listed. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one identifier: the child, child's parent or grandparent, for whom you can provide membership information.

Write the name and address of the organization that maintains updated and accurate membership data for such Tribe or Band of Indians. The name does not need to be the official name as it appears exactly on the Department of Interior's list of federally recognized Tribes, but the name must be recognizable and be of sufficient detail to permit verification of the eligibility of the Tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. Write the enrollment number establishing the membership for the child, parent or grandparent, if readily available, or other evidence of membership.

Provide the printed name of parent/guardian and signature, address, phone number and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3W238, Washington, D.C. 20202-6335

Write the name of the child, date of birth, grade level, name of school and school district. Only name one child per form.

OMB Control No. 1810-0021 (Exp. 01/31/2024)

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count for the Title VI Indian Education Formula Grant Program. If you choose to submit a form, your child could be counted for funding under the program. The grantee receives the grant funds based on the number of eligible forms counted during the established count period. You are not required to complete or submit this form unless you wish for your child(ren) to be included in the Indian student count. This form should be kept on file with the grant applicant and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

Name and address of Tribe or Band that maintains updated and accurate membership data for the individual listed above:

I verify that the information provided above is true and correct to the best of my knowledge and belief.

Poplar School District Policy (STUDENTS 3612-updated July 2009)

Student Use of Computers, Local area network, and Internet

Internet access is available to the District's students, faculty, and community members. Through its computer network, the District is connected with thousands of computers all over the world. Users may have access to information ranging from different cultures, science related issues, music, politics, and access to many university library catalogs. These are just some of the areas users may be able to explore through the computer network.

Students utilizing school-provided Internet access are responsible for good behavior on-line, just as they are in a classroom or other area of the school. The same general rules for behavior and communications apply. The District may provide filtering software for computers accessing the Internet.

The purpose of District-provided Internet access is to facilitate communications in support of research and education. To remain eligible as users, students' use must be in support of and consistent with the educational objectives of the District. Access is a privilege, not a right. Access entails responsibility.

Users should have no expectation of privacy or confidentiality in the content of electronic communications or other computer files sent and received on the school computer network or stored in his/her directory. The school computer network's system operator, or other school employees, may at any time review the subject, content, and appropriateness of electronic communications or other computer files and remove them if warranted. Any violation of District rules will be reported to school administrators.

When sending electronic messages, students shall not include information that could identify themselves, other students, or staff. Examples of identifying information include last names, addresses, and phone numbers. Users' network passwords are provided for their personal use. Users should not share their password with anyone. Users should not log into the network with another user's login name and password. If a user suspects someone has discovered their password, they should change it or have it changed immediately. Users shall not intentionally seek information on, obtain copies of, or modify files, other data, or passwords belonging to other users.

Users shall not:

1. Copy and forward;
2. Copy and download; or
3. Copy and upload

to the network or Internet server any copyrighted material, without approval by the computer system operator, a teacher, or other school administrator. Copyrighted material is anything created by someone else. Examples include, but are not limited to reports, articles, pictures, music, or software. Do not plagiarize or steal others' work.

The use of the District network and the Internet is for educational purposes only. All sites containing pornography or sexually explicit materials (written or pictured) are off limits to users.

Poplar District has purchased a firewall from 8e6 Technologies to protect our network. This Internet appliance is outfitted with a content filter that blocks inappropriate sites. 8e6 Technologies maintains and regularly updates its content filtering database. It automatically passes those updates through to our firewall device. Each year, to remain compliant with CIPA regulations, we renew our content filtering subscription and block access to inappropriate sites. In addition we have posted a copy of our Internet Use Policy on our school Web site. The CIPA Requirement and district policy is included below for reference.

"Undertaking such actions" refers to actions related to implementation of the CIPA requirements that should be in place for Year 2002. These requirements are:

A Technology Protection Measure is a specific technology that blocks or filters Internet access. It must protect against access by adults and minors to visual depictions that are obscene, child pornography, or - with respect to use of computers with Internet access by minors - harmful to minors. It may be disabled for adults engaged in bona fide research or other lawful purposes. For schools, the policy must also include monitoring the online activities of minors,

The Internet Safety Policy must address the following issues: access by minors to inappropriate matter on the Internet and World Wide Web; the safety and security of minors when using electronic mail, chat rooms, and other forms of direct electronic communications; unauthorized access, including so-called "hacking," and other unlawful activities by minors online; unauthorized disclosure, use, and dissemination of personal information regarding minors; and measures designed to restrict minors' access to materials harmful to minors.

The authority with responsibility for administration of the school or library must provide reasonable public notice and hold at least one public hearing to address a proposed Technology Protection Measure and Internet Safety Policy.

Students are prohibited from using e-mail except E-mail provided by the district Students are prohibited
from joining chat rooms, unless it is a teacher-sponsored activity.

Users shall not infiltrate or "hack" outside computing systems or networks. Examples: the release of
viruses, worms, or other programs that damage or otherwise harm an outside computing system or
network. Users shall not disrupt a system or interfere with another's ability to use that system (e.g., by
sending "e-mail bombs" that cause a disk to fill up, a network to bog down, or a software application to
crash). Nor shall users do any of these things to the District computer system.

Users shall not use the District computer network to:

1. Purchase goods, solicit sales, or conduct business (e.g., by posting an advertisement to a news group).
Users shall not set up web pages to advertise or sell a service.

2. Transmit obscene, abusive, sexually explicit, inappropriate, or threatening language.

I have read the above document and understand the conditions for accessing Internet at
Poplar Public Schools. I further understand that violation of the regulations may mean the
revocation of my Internet privileges and disciplinary action.

As the parent or guardian of this student, I understand that
this access is designed for educational purposes and that it is impossible for the Poplar Public Schools to
restrict access to all controversial materials. My signing this agreement indicates I will not hold Poplar
Public Schools nor its staff, administration, nor Board of Trustees responsible for materials this student
may acquire on the Internet. I hereby give my permission for the above named student to obtain Internet
access.

If you did not receive a copy of the Board Policy concerning these issues, please ask for one.

This agreement and its provisions are subject to revision
as deemed necessary by the Board of Poplar Public School Districts.