Disclosure Document
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First Name *
Last Name *
Student Email *
Class(es) You are involved in (Check All that apply) *
Parent First Name *
Parent Last Name *
Parent Email
Parent Phone Number
Best way to contact parent if needed *
IN THE FOLLOWING SPACE, PLEASE EXPLAIN ANY LEARNING CHALLENGES THAT YOUR STUDENT MAY HAVE THAT WILL HELP ME HELP THEM: This information is optional and confidential and will only be used to benefit your student. I am interested in making every kid successful. (If your student has an Individual Education Plan “IEP” you may wish to make me aware of that so I can research that now.)
Please check the appropriate box for your child’s participation in the different Film Studies that may be used in the class *
Films Not allowed to participate in
I Understand that... *
I Understand that... *
I am the parent/legal guardian of the above student and I have read the disclosure document *
I, as a student of the stated class, have read, understand and agree to follow the information outlined in the disclosure document *
Any questions, Comments or Concerns?
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