BCS Student Information Change Form

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Child’s Name:

Name of Person Requesting Change:

Relationship of the Above Person to Child:

Child’s School:

Barbour County Primary School

Barbour County Intermediate School

Barbour County High School

Clear selection

The following person as a contact for this student needs to be added or deleted. If you are deleting a contact please put the person name in the other category. Please put the updated information on the next question.

ADD

DELETE

Other:

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Parent/Guardians Name:

Parent/Guardians Address:

Parent/Guardians Home Phone:

Parent/Guardians Cell Phone:

Email:

This person is:

Legal Guardian

Emergency Contact

Authorized to Pick Student Up From School

Copied on School/District Correspondence

Living with Student

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PTA/PTO Directory: I permit that parent/guardian name and contact information to be included in the PTA/PTO directory.

YES

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Internet Acceptable Use Policy for Students: My student agrees to follow the Barbour County School District AUP on the use of the network or internet, will use these tools in a responsible way, and will obey all the rules explained by the school.

YES

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Internet Acceptable Use Policy for Parents: I have read the Barbour County School District AUP and grant permission for the student named above to access the network and internet. I understand that network and internet access is intended for educational purposes. I also understand that every reasonable precaution has been taken by the district to provide for online safety, but the district cannot be held responsible if students access unsuitable websites.

YES

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Media and Publicity Exclusion: My child may be featured in district publicity including advertisements, website, internet, district publications, educational videos, and media news stories.

YES

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Family Educational Rights and Privacy Act (FERPA): I permit my child’s name, birthdate, address, enrollment dates, phone number, email address, awards, height/weight, activity participation, gender, intended field of student, and grade level to be included in directories, as applicable, such as yearbook, group photos, phone directories, vendor lists, honor roll lists, sports rosters, institutions of higher education (ie: for scholarships), and activity programs.

YES

Clear selection

Military Services Opt-Out: I permit that my student’s name, address, and telephone number be released to Armed Forces, military recruiters, and/or military schools.

YES

Clear selection

Parent/Guardian Signature:

Today Date:

YYYY

Submit

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