2019 Contact/Health/Consent Form
Please complete the following information. Registration is not complete until this form has been submitted.
Contact Information
Child’s First Name: *
Your answer
Child's Last Name: *
Your answer
School: *
Birthdate: *
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DD
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YYYY
Grade Entering in September: *
Address: *
Your answer
City: *
Zip: *
Your answer
Home Phone: *
Your answer
Mother's Name: *
Your answer
Cell: *
Your answer
Email: *
Your answer
Father's Name: *
Your answer
Cell: *
Your answer
Email: *
Your answer
Are there any legal custody restrictions we should be aware of? *
If your child attends the Wyckoff Public Schools, do you give permission for The Summer Academies to access records in Genesis? *
List in order of preference, emergency contacts to be called if parents CANNOT be reached. In case of emergency, children will only be released to those named. *List the name(s) and phone number(s) below. *
Your answer
Health Information
In case of an illness or accident, parents will be contacted first. If a parent cannot be reached, The Summer Academies will contact people listed on the emergency list provided above.
Physician's Name: *
Your answer
Phone: *
Your answer
Dentist's Name: *
Your answer
Phone: *
Your answer
Does your child have any life threatening allergies or medical concerns? *
If yes, please list any life threatening allergies or medical concerns.
Your answer
Does your child take any daily medications? *
If yes, please list medications and dosage.
Your answer
If your child has an order for epinephrine or needs any medications given during the summer program, please provide the following on the first day of school:
1. Medication in its original container.
2. Written orders by your healthcare provider
3. Your written permission to administer medication
In order to maintain your child’s health and safety, allergy and/or medical concerns may be shared with pertinent staff.
Acceptable Use Agreement
Use of the Internet for instructional purposes by students and staff members is commonplace in the Wyckoff School District. The goal in providing this service to students and teachers is to promote educational excellence in our schools by facilitating access to resources, promoting innovative instruction, and increasing collaborative communication.
Along with access to computers and people all over the world comes the availability of material that may not be considered of educational value in a school setting. The Board requires school administrators and teachers to take precautions to restrict access to controversial materials by educating students about their responsibility to use the Internet appropriately.

Student use of the district’s Internet connection is a privilege, not a right. Inappropriate use will result in suspension or revocation of those privileges. Students are expected to abide by the generally accepted rules of Internet etiquette. These include (but are not limited to) the following:
1. Be polite. Do not become abusive in your messages to others.
2. Use appropriate language. Do not swear, use vulgarities or any other inappropriate language. Illegal activities are strictly forbidden.
3. Do not reveal your personal address or phone number.
4. Only access acceptable Internet sites.
5. Note that electronic mail (e-mail) is not guaranteed to be private. People who operate the system do have access to all mail. Messages relating to or in support of illegal activities may be reported to the authorities.

All communications and information accessible via the Internet should not be assumed to be private property.
A complete version of Policy and Regulation #2361, “Acceptable Use of Computer Network/Computers and Resources” can be found on the District Website at www.wyckoffps.org under the Board of Education tab. Please carefully review the Policy and Regulation and agree to the terms of the Acceptable Use Agreement and Web Information.
PARENT OR GUARDIAN AGREEMENT: (Since applicant is under the age of 18, a parent or guardian must also read this agreement.) As the parent or guardian of this student, I have read the Acceptable Use Agreement, reviewed the Board of Education Policy and Regulation #2361, and grant permission for my son or daughter to access the Internet. I confirm that I have advised my child to abide by the provisions stated. I understand that this Internet access is designed for educational purposes. I understand the Wyckoff School District has taken precautions to eliminate controversial material through supervision and instruction. However, I also recognize it is impossible for the Wyckoff School District to prevent access to all controversial materials, and I will not hold them responsible for materials acquired by my child on the internet. *
STUDENT AGREEMENT: I have read the Acceptable Use Agreement describing the Wyckoff School District’s acceptable use of the Internet and agree to abide by those provisions. I understand that violation of the use provisions stated in the policy/regulation will constitute suspension or revocation of Internet privileges. *
Photo Consent
We are providing you with this parental consent form to both inform you and to request permission for your child’s photo/image to be published on the Summer Academies and Wyckoff School District's web sites, Facebook, Twitter, Instagram, cable channel, or in printed media.

As you are aware, there are potential dangers associated with the posting of personally identifiable information on a web site since global access to the Internet does not allow us to control who may access such information. These dangers have always existed; however, we as schools do want to celebrate your child and his/her work. The law requires that we ask for your permission to use information about your child.

Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes student names, photo or image, residential addresses, e-mail address, phone numbers and locations and times of trips.

If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending an email to Dr. Pepe, the Director of the Summer Academies at summer@wyckoffschools.org and such rescission will take effect upon receipt.
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