Student Enrollment Form
Information provided on this form is for the 2024-2025 school year.  

Please complete a separate form for each student attending Breathitt County Area Technology Center.

Checking the boxes beside the statements signifies your consent for each item , you are acknowledging that the parent/guardian and/or student listed has read and understands the expectations, rights, responsibilities and/or guidelines for each item as it relates to the student.



Equal Education and Employment Opportunities M/F/D
Email *
Student Name *
Parent / Guardian Name(s) *
Full Street Address *
Student Birth Date *
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Primary Phone Number *
Today's Date *
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YYYY
Student Grade Level *
ATC Program(s) (Check all that apply) *
Required
Student Enrollment Agreement
I have read and understand the Student Grievance Procedure, Nondiscrimination Policy Statement, Code of Conduct, Harassment Policy and Drug Free Policy that pertain to my enrollment in the Breathitt County Area Technology Center.  (See the Breathitt County Area Technology Center Student Handbook for all policies and procedures) Student Handbook *
Required
I understand that my records will only be released to unauthorized agencies or personnel upon written request by my parents or guardian if I am under 18 years of age, or my signature if I am 18 years of age or older. This is in compliance with the Family Rights and Privacy Act of 1974. *
Required
Field Trip and Off-Campus Training Project Permission for Short Trips (Not Requiring Overnight Stays)
From time to time during the school year, various classes at the Breathitt County Area Technology Center will be going on class trips and/or participating in Off-Campus Training Projects in and around the immediate area of our facility.  These field trips will always be under the supervision of the instructor of the class.

Some field trips will require bus travel.  In order to avoid repetition in securing your permission for these short trips, this form is designed to cover all trips to be taken during the school year.
I do hereby give permission for my student (listed above) to take part in short class trips in and around the immediate area of the school for the 2024-2025 School year.  I understand that some field trips will require bus travel. *
Student Work - Copyright Release
In consideration for the opportunity to enroll in the course(s) checked above, and for other valuable consideration, receipt of which is acknowledge, I hereby grant the Kentucky Department of Education, Office of Career and Technical Education and Student Transition (the “KDE”), permission to use the copyrighted materials I create during the course of the identifies class(es) (the “Work”).  I am granting the KDE permission for non-exclusive rights to use the written work(s), image(s), and/or art object(s) created in this course for educational and promotional purposes.  Such use may include incorporating my materials into an interactive media project and Web-based instructional and promotional materials *
Required
I irrevocably assign and transfer to the KDE, its successors and assigns all right, title, and interest in the Work and in the copyright thereon, together with the right to secure renewals, reissues, and extension of the copyright. *
Required
I am the sole creator and owner of the Work and the copyright, and have the legal right and authority to grant this assignment and release.  I have read this assignment and release, prior to its execution, and I am fully familiar with its contents. *
Required
Student - Media Information Release  
The Kentucky Department of Education, Office of Career and Technical Education and Student Transition, The Breathitt County Area Technology Center Has my permission to use my name and image (photo, video, digital, sketch, etc.) in any KDE or school-related public relations or public information materials for distribution or sale, and I release the Cabinet, its agencies and agents and assigns from any action at law taken as a result of use of my name and/or my photographs. *
Required
Student Enrollment - Computer Use Policy
The use of any computer equipment is a privilege.  Students must maintain the equipment in a considerate, responsible manner.  Failure to cooperate with this policy will cause the student to lose the privilege to use the equipment.  
As a student in the Computer Lab of a Kentucky Tech Area Technology Center, I have read and hereby agree to the policy and rules outlined below.  Specifically, the user is expected to abide by high school policy and the following rules:  1-Sit only at your assigned work station.  2-Keep your password private.  3-Do not bring any storage device into the computer classroom without first obtaining permission from your instructor.  4-Do not take your data storage device from the classroom for use on another computer system.  5-Do not plug or unplug any cable or cord connected to the computer system.  Unless instructed to do so by the teacher.  6-Do not change or delete any file except those files stored on your own student data storage device.  7-Do not mark on or deface any part of your work station.  8-Do not trespass in another’s folder, work, or files.  9-Do not eat or drink in computer classroom around computer equipment.  10-Do not attempt to hack or in anyway by-pass computer security measures.  11-Do not install software, plug-ins, music, pictures, viruses, etc. on a computer unless the teacher instructs you to do so. *
Required
Student Medical Record and Insurance Verification
Emergency Contact Name *
Emergency Contact Phone Number(s) (Home, Cell, Work) *
Emergency Contact Address *
Emergency Contact Relationship to Student *
Each student enrolled at the Breathitt County Area Technology Center should have some type of insurance coverage in the event of an injury.  Every precaution is taken to prevent injuries; however, accidents do happen occasionally.  The state provides limited secondary insurance coverage for students enrolled in the School.  
Name of Insurance Company
Policy Number
Group Number
Family Physician *
Physician Phone Number *
Hospital
Does the student have school insurance? *
If you have a state medical card, please provide the number.
Identify any of the conditions or diseases below that you have. (Check all that apply) *
Required
Are you taking any medications? *
If you answered yes to the previous question, please list medication(s)
List any allergies you have.
If I am unconscious and spouse or parent/legal guardian cannot be reached, I hereby give consent for the principal and/or teacher to do whatever is necessary to secure emergency medical care. *
A copy of your responses will be emailed to .
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