Acknowledgment Form - Schoolwires

Acknowledgment FormMy child and I have reviewed a copy of the Agua Dulce Secondary Student Handbook and theStudent Code of Conduct for 2017-2018. I understand that the handbook contains informationthat my child and I may need during the school year and that all students will be heldaccountable for their behavior and will be subject to the disciplinary consequences outlined inthe Student Code of Conduct.Printed name of student:Signature of student:Signature of parent:Date:“Please sign and date this page, remove it from the handbook, and return it to the student’sschool.”-i-

Acknowledgment of Electronic Distribution ofStudent HandbookMy child and I have been offered the option to receive a paper copy or to electronically access atwww.adisd.net the Agua Dulce Secondary Student Handbook and the Student Code of Conductfor 2017-2018.I have chosen to: Receive a paper copy of the Student Handbook and the Student Code of Conduct. Accept responsibility for accessing the Student Handbook by visiting the Webaddress listed above.I understand that the handbook contains information that my child and I may need during theschool year and that all students will be held accountable for their behavior and will be subject tothe disciplinary consequences outlined in the Student Code of Conduct. If I have any questionsregarding this handbook or the Code, I should direct those questions to the principal atcdaniels@adisd.net or at 361-998-2214.Printed name of student:Signature of student:Signature of parent:Date:- ii -

Notice Regarding Directory Information andParent’s Response Regarding Release of Student InformationState law requires the district to give you the following information:Certain information about district students is considered directory information and will bereleased to anyone who follows the procedures for requesting the information unless the parentor guardian objects to the release of the directory information about the student. If you do notwant Agua Dulce ISD to disclose directory information from your child’s education recordswithout your prior written consent, you must notify the district in writing within ten school daysof child’s first day of instruction for this school year.This means that the district must give certain personal information (called “directoryinformation”) about your child to any person who requests it, unless you have told the district inwriting not to do so. In addition, you have the right to tell the district that it may, or may not; usecertain personal information about your child for specific school-sponsored purposes. Thedistrict is providing you this form so you can communicate your wishes about these issues. [SeeDirectory Information on page 27 for more information.]- iii -

For the following school-sponsored purposes identified in FL (LOCAL)], AguaDulce ISD has designated the following information as directory information: Student’s name Address Telephone listing E-mail address Photograph Date and place of birth Major field of study Degrees, honors, and awards received Dates of attendance Grade level Most recent school previously attended Participation in officially recognized activities and sports Weight and height, if a member of an athletic team Enrollment statusDirectory information identified only for limited school-sponsored purposes remains otherwiseconfidential and will not be released to the public without the consent of the parent or eligiblestudent.Parent: Please circle one of the choices below:I, parent of (student’s name), (do give) (do not give) thedistrict permission to use the information in the above list for the specified school-sponsoredpurposes.Parent signatureDate- iv -

For all other purposes, Agua Dulce ISD has designated the following information as directoryinformation: Student’s name Address Telephone listing E-mail address Photograph Date and place of birth Major field of study Degrees, honors, and awards received Dates of attendance Grade level Most recent school previously attended Participation in officially recognized activities and sports Weight and height, if a member of an athletic team Enrollment statusParent: Please circle one of the choices below:I, parent of (student’s name), (do give) (do not give) thedistrict permission to release the information in this list in response to a request unrelated toschool-sponsored purposes.Parent signatureDate-v-

Parent’s Response Regarding Release of Student Information toMilitary Recruiters and Institutions of Higher EducationFederal law requires that the district release to military recruiters and institutions of highereducation, upon request, the name, address, and phone number of secondary school studentsenrolled in the district, unless the parent or eligible student directs the district not to releaseinformation to these types of requestors without prior written consent. [See Release of StudentInformation to Military Recruiters and Institutions of Higher Education on page 27 formore information.]Parent: Please complete the following only if you do not want your child’s information releasedto a military recruiter or an institution of higher education without your prior consent.I, parent of (student’s name), request that the district notrelease my child’s name, address, and telephone number to a military recruiter or institutions ofhigher education upon their request without my prior written consent.Parent signatureDate- vi -

Dear Parent:The district is required by federal law to notify you and obtain your consent for or denial of (optout) for your child’s participation in certain school activities. The activities include any studentsurvey, analysis, or evaluation, known as “protected information survey” that concerns one ormore of the following eight areas:1. Political affiliations or beliefs of the student or student’s parent;2. Mental or psychological problems of the student or student’s family;3. Sexual behavior or attitudes;4. Illegal, antisocial, self-incriminating, or demeaning behavior;5. Critical appraisals of others with whom the student has a close family relationship;6. Legally recognized privileged relationships, such as with lawyers, doctors, or ministers;7. Religious practices, affiliations, or beliefs of the student or parents; or8. Income, other than as required by law to determine program eligibility or to receivefinancial assistance under such a program.This notice and consent/opt-out requirement also applies to the collection, disclosure, or use ofstudent information for marketing purposes (“marketing surveys”), and to certain physical examsand screenings.The following are activities requiring parental notice and consent or opt-out for the 2017-2018school year. Please note that this notice and authority to consent transfer from the parent to thestudent when the student reaches 18 or is an emancipated minor under state law.“A parent must sign and return this consent form no later than Aug. 31st, 2017 if you wouldpermit your child to participate in this survey.”Parent’s signatureContact Dr. Chris Daniels at 998-2214, cdaniels@adisd.net if you do not want your child toparticipate in this activity.”If you wish to review any survey instrument or instructional material used in connection withany protected information survey, please submit a request to 1 Longhorn Drive, Agua Dulce,78330. Dr. Chris Daniels will notify you of the time and place where you may review thesematerials. You have the right to review a survey and/or instructional materials before the surveyis administered to a student.- vii -

Date: 2017-2018 School YearGrades: 6-12Activity: Student-Based Commercial ServicesSummary: The Agua Dulce Secondary collects, or allows businesses to collect, use, anddiscloses personal information on students; these businesses provide student-based products andservices.To consent: A parent must sign and return the consent form no later than Aug. 31st, 2017 if youwould permit your child to participate in this activity.Parent’s signatureIf you wish to review any survey instrument or instructional material used in connection withany marketing survey, please submit a request to Dr. Chris Daniels will notify you of the timeand place where you may review these materials. You have the right to review a survey and/orinstructional materials before the survey is administered to a student.- viii -

NOTICES TO PARENTSStatement of NondiscriminationIn its efforts to promote nondiscrimination, Agua Dulce ISD does not discriminate on the basisof race, religion, color, national origin, gender, or disability in providing education services,activities, and programs, including vocational programs, in accordance with Title VI of the CivilRights Act of 1964, as amended; Title IX of the Educational Amendments of 1972; and Section504 of the Rehabilitation Act of 1973, as amended.The following district staff members have been designated to coordinate compliance with theselegal requirements: Title IX Coordinator, for concerns regarding discrimination on the basis of gender: Mr.Wayne Kelly, Superintendent of Schools, PO Box 250 Agua Dulce, Texas 78330 361-9982542. Section 504 Coordinator, for concerns regarding discrimination on the basis of disability:contact Mr. Wayne Kelly, Superintendent of Schools, PO Box 250 Agua Dulce, Texas 78330(361) 998-2542. All other concerns regarding discrimination: Contact Mr. Wayne Kelly, Superintendent ofSchools, PO Box 250 Agua Dulce, Texas 78330 (361) 998-2542.Asbestos Management Plan The district’s Asbestos Management Plan, designed to be in compliance with state andfederal regulations addressing asbestos, and is available in the Superintendent Office. If youhave any questions, please contact Mr. Wayne Kelly, PO Box 250 Agua Dulce, Texas 78330(361) 998-2542.Pest Management Plan The district applies only pest control products that comply with state and federal guidelines.Except in an emergency, signs will be posted 48 hours before application. Parents who wantto be notified prior to pesticide application inside their child’s school assignment area maycontact Dr. Chris Daniels, PO Box 250 Agua Dulce, Texas 78330 (361) 998-2214Additional NoticesOther important notices in the Student Handbook cover the following topics: Student participation in a survey, analysis, or evaluation;Opting out of surveys and data collection activities;Requesting the professional qualifications of teachers and staff;Requesting a transfer of your child to a safe public school;Assistance to students who have learning difficulties;Student records;Bacterial meningitis;Career and technology programs;Homeless students; andSchool lunch programs.Please take some time to review these notices and other important information contained in theStudent Handbook.- ix -