Elm Road 2023-2024 Back to School Consent Form
Please carefully review and select responses to the questions on this form that are required for the 2023-2024  School Year.

The required consents are for:-

Handbook Certification
Consent to Publish
PHM Mandatory Curriculum

Please complete one google form for EACH student attending PHM School Corporation
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Email *
Student First Name *
Student Last Name *
Student 6 digit P-H-M ID Number *
If you do not know your students P-H-M ID number, please enter 0.
Grade *
Parent/ Guardian Name *
Student Handbook Certification:

We have received and read the handbook. We understand the rights and responsibilities pertaining to students and agree to support and abide by the rules, guidelines, procedures, and policies of the PHM School Corporation.
Do you confirm receiving the handbook *
Consent to Publish Student Work and Photographs:

At Penn-Harris-Madison School Corporation we value the strong communications we have with our families and community partners. Our students, teachers and staff are actively involved in many activities often winning school, local, state, national or international recognitions. We are proud of the amazing work accomplished by all our students. As part of our ongoing communication efforts, the District and/or Schools would like to spread the good news about these accomplishments.

Photographs, video and/or audio may be taken of students and/or Student Work (as hereinafter defined) as a part of a curricular project, to promote a school event or to showcase student achievement.  The Penn-Harris-Madison School Corporation (the “School Corporation”) may use images and names of students and/or Student Work on any form of printed or digital communication, including P-H-M District or school websites, social media and newsletters. As part of P-H-M’s public relations efforts, your student’s achievement and/or involvement can also be shared with third party news media outlets. “Student Work” includes, but is not limited to: drawings; materials; writings; photographs; and images.

I understand that by signing this form I hereby give permission to post and/or publish photographs, the name, and/or Student Work of my child on the aforementioned websites, social media and any form of digital or written publication.  I understand and agree that my child is not entitled to any compensation for Student Work or images appearing in said printed and/or digital communications.

 Please note that this consent form cannot apply to public events.  If your child attends or participates in an event that is open to the general public, such as a P-H-M athletic, theater, band, orchestra, choir, academic competition or another type of school or district sponsored activity, pictures might be taken and used in the before names district communications.

Do you agree with the Consent to Publish *
PHM Mandatory Curriculum- Protect Yourself Rules :


Indiana law (IC 20-19-3-11) requires that all schools provide age appropriate and research based instruction on child abuse and child sexual abuse to students in kindergarten through grade 12. Penn-Harris-Madison has partnered with the Youth Service Bureau of St. Joseph County to provide this instruction for our students in grades kindergarten through fifth grade.

During the first semester of the school year, staff from Youth Service Bureau of St Joseph County will present a series of age appropriate, short animated videos that will be followed by a short session asking the children what they learned from the videos, did they understand the messages etc. This curriculum, designed by the Barbara Sinatra Children’s Center at Eisenhower Medical Center, is called the “Protect Yourself Rules.”

The program’s main goal is to educate children about what to do when confronted with abusive behavior, safe and unsafe touches, going to a parent or another trusted adult if they are confronted in an unsafe situation, and that it is not their fault. An “Unsafe Touch” is defined as touching private parts of the body that are covered by a bathing suit. Stranger safety, Internet safety and other situations are also presented. The curriculum can be viewed at https://fightchildabuse.org/. Below, you will find the different videos that are shown to students during the lessons. If you would like to view the videos, please find them on the “Fight Child Abuse” website under the “Pick Your Age Group” option.

● K-3 watches the following videos:

○ Protect Yourself Rules (Introduction)
○ Safe touch/Unsafe Touch
○ Shout Run Tell
○ Neighbor
○ Recognize The Signs

● Grades 4-5 watches the following videos:

○ Protect Yourself Rules
○ Secrets
○ Can't Go Home
○ Tell
○ Smart Choices Online

If you have additional questions, please feel free to email Ms. Laurie Ellis at lellis@phm.k12.in.us, who is the Supervisor of Youth Development Services at Youth Service Bureau.
Do you wish for your student to participate in the program *
Parent/Guardian completing this form *
A copy of your responses will be emailed to the address you provided.
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