I give my permission for the staff of Teton Literacy Center, this 21st CCLC program with services located at Teton Literacy Center, Jackson Elementary School, and Jackson Hole Middle School to review my child’s academic and behavior progress reports or their report card in order to document growth and progress in my child during his/her time in this before/after school or summer program. This Authorizes Teton Literacy Center, Teton County School District # 1 to share written or verbal information regarding my child’s academic performance, diagnosis, history, including medication, progress, psychological and educational testing, medical and legal information, social welfare and rehabilitation, reports and other materials that are relevant to my care. This includes attendance, academic performance, teacher surveys and information about whether my child has an identified exceptionality, an Individual Education Plan or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the program. TLC will send Wyoming Department of Education grade reports from your child’s teacher using WISERID numbers where data will be aggregated at the state level to protect your child’s identification. This data is collected to evaluate the effectiveness of TLC programs.
I understand that my records are protected under the laws regarding confidentiality, and cannot be disclosed without written consent, except in specific situations. This consent is valid throughout my child receiving services at Teton Literacy Center.
I hereby give permission to Teton Literacy Center
To obtain medical or surgical care from a health care facility, physicians or dentists for my child should the need arise. It is understood that a conscientious effort will be made to locate me before action will be taken. If this is not possible, treatment as deemed necessary by the physicians/dentists may be taken. I further consent to transportation of the above named child to the nearest or most appropriated medical facility. I authorize the hospital and attending physicians to submit claims to the above named company and hereby assign benefits directly to this company. I understand that I am financially responsible to providers of service for charges not covered by any insurance payments.
The Teton Literacy Center may photograph, interview, or videotape my children to use for volunteer instruction, marketing purposes and/or program fundraising. Please indicate below whether your child’s writings or photograph may be used for these purposes:
I give my child permission to join the Teton Literacy Center for off-campus outings, to ride into downtown Jackson via Start Bus with Teton Literacy Center staff and volunteers to visit local area organizations. Students will ride the START BUS with Teton Literacy Staff and volunteers and Teton Literacy Staff will drive a van or other vehicle to Grand Teton National Park or any other offsite location. TLC will notify parents if students will leave designated TLC site prior to field trip.
This Teton Literacy Program is funded through 21st Century Community Learning Centers funding, which is a FREE PROGRAM for students that could benefit from a variety of stimulating personal enrichment activities that promote school success and well-being in a safe environment. Active attendance and engagement are essential to the student and program’s success.
I understand that the requirements of the program include the following:
Appropriate behavior must be maintained. If there are any disruptive students, every effort will be made to work with the parents to resolve the matter. However, TLC may remove the student from the program if any of the following occurs:
· Verbal abuse or physical abuse of a tutor, teacher or staff member.
· Disruptive behavior that affects other learners.
· Disregard for the TLC or school premises.
I have read, understand and agree to comply with the requirements of the policies and procedures listed above. I realize that failure to comply with these requirements may result in loss of my funded space within this program. I release the Teton Literacy Center, its staff, Board of Directors and volunteers from any liability.