Beresford 6-12 School Registration Forms
Name of Parent/Guardian Completing Form *
-By entering your name below, you are indicating that you are the person you say you are and this electronic signature indicates you are providing permission, consent, and/or information for the questions that follow.
Your answer
Student Last Name *
Your answer
Student(s) First Name *
-If you have more than one student, enter all first names in the space below (please separate names with a comma and start with your oldest child).
Your answer
Grade(s) of Student *
-If you have more than one middle/high school student, select all that apply.
Required
Student Birthdate *
-If you have more than one school student, enter all dates by starting with your oldest child and separating entries with a comma.
Your answer
Primary Household Address *
Your answer
Secondary Household Address -If applicable
Your answer
Primary Telephone Number *
-What is the best number(s) to contact you?
Your answer
Secondary Telephone Number -If applicable
-What is the best number(s) to contact you?
Your answer
Primary Parent Email Address *
-What is the best email address to use when sending out informational updates?
Your answer
Secondary Parent Email Address -if applicable
-What is the best email address to use when sending out informational updates?
Your answer
Acceptable Use Policy *
Please read and review the following link pertaining to the Beresford School District's Acceptable Use Policy: https://drive.google.com/open?id=1uhJYrpfxyi0rYAuFHjtpI5Qo5DMacQWf.
Student Health Conditions *
Please identify any health conditions your child has that may at some time pose a problem for him/her in the classroom or at school-related activities (examples—asthma, epilepsy, diabetes, allergies, etc.). If YES, check other and list child's name and health condition.
Required
Field Trip Permission *
In order to help parents, children, and the schools, we are asking for your written/electronic consent to take your child on class field trips during their middle and high school years. This authorization will eliminate the need for special permission before each trip and will assure each child an opportunity to be included in such excursions. An attempt will be made by the supervising teacher to inform parents of the times and places that the class may visit. Class field trips may include trips in and out of town. Students will be transported in school buses or school vehicles.
Meals on Wheels *
Beresford students (grades 6-12) are given the opportunity to volunteer their time to assist in delivering Meals on Wheels during the school day. Students are picked up at school and ride along with adult drivers. Names of students who enter yes on this question will be kept on a master list to be called upon when needed. A delivery schedule will be posted in the hall. Volunteers are picked up at the school office at 11:15 and usually are done in less than one hour. They may eat lunch upon returning to school.
Acknowledgment of Review of Student Handbook *
Please read the contents of the student handbook. Each handbook is available online at https://www.evernote.com/l/AOHX-exFhe5ANoZdHTBZoeOgy8SFIMFN-m8. The direct link to the BHS handbook is: https://drive.google.com/open?id=1eCqU1Vm9QV668jPro5G61E9fHKUyDWpN. The direct link to the BMS handbook is: https://drive.google.com/open?id=1z6UByiktt_tz-eFgahaZCiLGA_Llgmm3. If you would like a hard copy, please contact the appropriate school office. If you have any concerns or questions, please contact the principal. Each student/learner and parent is expected to review and understand the contents of applicable student handbooks.
Activities Code of Conduct/Eligibility Rules *
We have read the Beresford School District “Co-Curricular Activities Code of Conduct/Eligibility Rules." Having done so, we understand, support, and will abide by these guidelines. Link to Code of Conduct section: https://drive.google.com/open?id=1DzM0UTseoao_VeLJimYbVewt4sLg-tun.
Catastrophic Trauma Insurance *
The Beresford School District 61-2 provides catastrophic trauma insurance for all student-athletes who are participating in interscholastic athletic activities only. The School District does not provide separate student accident coverage or separate dental coverage for any students. Separate student accident insurance and separate dental insurance forms are available to all students at student orientation at the beginning of the school year for purchase at the option of the parent/guardian. This consent question needs to be answered by all parents/guardians even if you are not taking the insurance and/or your child is in co-curricular activities.
Co-Curricular -Parent or Guardian Permission *
I give my permission for my son/daughter to participate in organized athletics, realizing that such activity involves the potential for injury that is inherent in all sports.
Co-Curricular -Parent Consent for Medical Treatment *
I am the mother/father/legal guardian for the child listed on this form (or children listed on this electronic form) who participates in co-curricular activities for Beresford Schools. I hereby consent to any medical services that may be required while said child is under the direct supervision of an employee of the Beresford School District while on a school-sponsored activity and hereby appoint said employee to act on behalf in securing necessary medical services from any duly licensed medical provider.
Co-Curricular -Child Consent for Medical Treatment
I, enter name below (e.g. child enters name below, if more than one child -each child's name needs to be entered), have read the above Parent Consent for Medical Treatment section that has been signed by my parent/guardian and join with him/her in the consent. If your child does not participate in co-curricular activities, please leave this question blank.
Your answer
Consent for Release of Medical Information (HIPPA) -Form to be completed annually and must be available for inspection at the school. *
1. I authorize the use or disclosure of the above named individual’s health information including the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a student’s ability to participate in South Dakota High School Activities Association sponsored activities. A Health Care Provider generating or maintaining such information may make such disclosure. 2. The information identified above may be used by or disclosed to the athletic trainer, coaches, medical providers and other school personnel involved in the care of this student. 3. This information for which I am authorizing disclosure will be used for the purpose of determining the student’s eligibility to participate in extracurricular activities, any limitations on such participation and any treatment needs of the student. 4. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. 5. This authorization will expire on July 1, 2019. 6. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 7. I understand authorizing the use or disclosure of the information identified above is voluntary. However, a student’s eligibility to participate in extracurricular activities depends on such authorization. I need not sign this form to ensure healthcare treatment.
Parental Insurance Waiver *
We wish to emphasize that the Beresford School District does not provide any type of health or accident insurance for injuries incurred by your child at school. We encourage families to have accident coverage on their children, prior to participation in any sports or school sponsored activities. Since children are particularly susceptible to injuries, we encourage you to review your present health and accident insurance program to determine if your coverage is adequate. If you do not feel your insurance is adequate because of a deductible or coinsurance clause, or if you do not have insurance, we encourage you to review the student insurance program. This plan will provide benefits for medical expenses incurred because of an accident. An explanation of the cost and benefits is explained on the premium envelope. Plan options can be reviewed by browsing the insurance brochure(s) located in the middle and high school offices.
HSPAC (High School Parent Advisory Committee) or MSPAC (Middle School Parent Advisory Committee) *
The purpose of the committee is to be a sounding board for the principal (e.g. members will review and analyze school practices, help project future needs, and provide valuable input about school practices). More so, group members will be kept informed about events happening at the school and their input will be utilized in the decision-making process by the principal and administrative team. The MSPAC and HSPAC will meet every two months.
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service