LHS 10th Grade Community Agency Opt-Out Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

Dear WSD Family,

Throughout the duration of the academic year, the Wentzville School District partners with community agencies that specialize in providing students, families, and educators with preventative education. Agency presenters are credentialed, coordinated throughout the District, and under the supervision of building administrators. Presentation topics are targeted toward specific grade levels. All students will participate in each program, unless you choose to opt your child out of the lesson(s). The programs that are scheduled for 10th grade are listed below:

Program/Topic: Sexual Abuse Prevention*

Community Agency: The Child Center

This particular program is designed to educate and empower students by providing them with knowledge and skills that can be utilized if they are impacted in any way by sexual abuse. This presentation concludes with a brief survey to assess understanding and/or needs regarding sexual abuse concerns.

*Please note that in accordance with section 170.045 RSMo., school districts are required to provide age and developmentally appropriate sexual abuse prevention education to students. Under Missouri Law, this education will include the following components, at a minimum:

1) Instruction providing students with the knowledge and tools to recognize sexual abuse,

2) Instruction providing students with the knowledge and tools to report an incident of sexual abuse,

3) Actions that a student who is a victim of sexual abuse could take to obtain assistance and intervention, and

4) Available resources for students affected by sexual abuse.

Notice of when the program will be presented will be provided by your child's school. If you do NOT wish for your child to participate, please click the box below. (By leaving the box unmarked, your child will be permitted to participate.)

I do NOT wish for my child to participate in Sexual Abuse Prevention.

Program: Self Injury

Topic: Suicide Prevention*

Community Agency: CHADS Coalition

Students learn about warning signs and risk factors for self-injury, with an emphasis on healthy coping skills and the importance of staying mentally and physically healthy. The acronym "ACT" (acknowledge, care, tell) is shared, as are coping skills for dealing with difficult situations. This presentation includes a brief student survey to assess understanding and/or needs regarding mental health concerns.

*Pursuant to Section 170.048 RSMo., school districts are required to have in place a policy that addresses and includes, but is not limited to, the following:

1) Strategies that can help identify students who are at possible risk of suicide;

2) Strategies and protocols for helping students at possible risk of suicide; and

3) Protocols for responding to a suicide death.

The Wentzville School District addresses this state statute through Policy 2785.

I do NOT wish for my child to participate in Self-Injury: Suicide Prevention.

Student's First Name: *

Student's Last Name: *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Wentzville R-IV School District. Report Abuse

Forms