ESE STUDENT ONLY: In accordance with FERPA, at 34 CFR §99.30 and IDEA requirements, I authorize the School District of Palm
Beach County, Florida, to release and exchange my child's confidential student information to agencies of the State of Florida which
would allow Palm Beach County Public Schools to receive Medicaid reimbursement for health related exceptional student services it
provides to my child while at school. I understand my consent is voluntary and may be revoked at any time. My child will continue to
receive services as per his/her IEP whether or not I give consent. In addition, I understand that I am not required to enroll in any public
benefits or insurance program and that no out of pocket expense will be incurred for services provided as a part of FAPE, and that
there is no impact to my Medicaid benefits as a result of the school district's reimbursement for services.
Student ID #
Student Legal Name (first, middle initial, last)
The School District of Palm Beach County
New and Returning Student Registration
PBSD 0636 (Rev. 3/12/2020) RECORD COPY - Student Cumulative Record Folder Page 3 of 3
Read the following carefully. Check available appropriate boxes below statements and sign below.
You are invited to read this Policy, Manual and Notice. If you need assistance reading the documents, you may ask the school for assistance. The
policy is available at: https://www.boarddocs.com/fl/palmbeach/Board.nsf/Public, click Policies, under chapter 8 --Policy 8.123.
Notice of Technology Acceptable Use Policy For Students: Your child may have access at school for many school-related
activities to certain District technology resources, including the Internet and the District's Intranet. Your child's school's access to the
Internet is filtered to comply with the Children's Internet Protection Act and School Board Policy 8.125. Your child will be required to
follow the acceptable use standards and guidelines that are stated in Policy 8.123, the referenced Manual, and the Notice of
Conditions for Student Use of District Technology and be bound by their terms. There is only a limited expectation of privacy to the
extent required by law related to a student's use of these technology resources. Before your child uses these District resources, he/she
will read, be read to, and/or explained these documents and will electronically acknowledge that he/she understands, and agrees to
follow, them.
Notice of medical records disclosure: Your child's medical records or medical information that have been provided to the school are
student records which are subject to the requirements of FERPA, 20 U.S.C.A. 1232g. Accordingly, that information can be disclosed
without the written consent of the parent/guardian as allowed by FERPA, including if used by a teacher or other school official, who has
a legitimate educational interest, or if disclosure is to an appropriate party and is necessary to protect the health or safety of the
student or other individuals.
Parental consent for release of student photograph and information: I hereby give permission for the school or District to use my
child's photograph, video image, writing, voice recording, name, grade level, school name, participation in officially recognized activities
and sport, weight and height of members of athletic teams, dates of attendance, diplomas and awards received, date and place of
birth, and most recent previous school attended, in annual yearbooks, graduation programs, playbills, school productions, web sites,
social media sites, etc. and/or similar school or District sponsored publications or in school or District approved news media interviews,
releases, articles, and photographs. I also provide permission for the release by the school or District to the media and governmental
entities of my child's name, grade, school name and honors my child has received for public announcement of recognition of my
student's accomplishments. I understand that without checking the permission box my child's name and photograph cannot and
will not be included in any publications or presentation, including a school yearbook.
I give permission I do not give permission
I authorize release
I do not authorize release
Under penalties of perjury, I declare that I have read the foregoing form and that the facts stated in it are true and accurate. Florida
Statutes Sec. 92.525 (3) provides that whoever knowingly makes a false declaration under penalties of perjury is guilty of a felony of
the third degree.
HIGH SCHOOL STUDENT ONLY - Opt-out for the release of information to military: The NCLB Act of 2001 requires that school
districts provide military recruiters access to the names, addresses and phone numbers of high school students. Parents have a right
to OPT-OUT from sending this information. If you do not want your child's information released to the military without prior written
parental consent, check below. Although we will accept the opt-out any time during the year, sending it the first 10 days of the school
year will ensure that no information is sent this school year.
I do not authorize release of my child's information to the military
By signing below, I understand and agree it is my responsibility to contact my child's school immediately to inform them of any changes
to my contact information including name, address, home or cell phone numbers or e-mail address. If I agreed to accept text
messages on my cell phone, I understand standard messaging rates with my cellular phone provider may apply. If I opted out of
informational messages, I will continue to receive emergency phone messages from or on behalf of the School District of Palm Beach
County at the telephone number(s) provided on page 2, including a wireless number if applicable. If you received non-emergency
messages without consenting and/or would like to opt out of future calls, contact (855) 502-7867.
REGISTRATION IS NOT VALID WITHOUT SIGNATURE AND DATE.
Date
Parent/Guardian Signature (unless student is emancipated)
