Athena Academy Forms Parent Name (print)________________________________ Parent Name (sign)_________________________ Parent Name (print)________________________________ Parent Name (sign)_________________________ Parent E-mail_____________________________________ Parent E-mail_____________________________ Parent Cell Number________________________________ Parent Cell Number______________________ Home Phone Number______________________________ Student Name____________________________________ Yes No Permission to publishing cell phone in Student Roster Permission to publishing email addresses in Student Roster * Failing to mark box means these will be published. Athena Academy ACCEPTABLE USE POLICY Please read, sign and return the 1st day of school This document serves as a means of promoting responsible use of technological resources provided by Athena Academy. Here are the expectations for student use of computers, network resources, and the internet at our school. Parents, please review this with your child. Access to the Internet allows connections to computer systems located all over the world. Athena Academy employees cannot control the information found on the Internet. We have taken steps to reduce access to “adult” sites; however, we cannot prevent access to all inappropriate content. Some available information may be controversial and may even be offensive to some individuals. All students and parents using technology at Athena Academy will: 1. Agree that the primary use of school technology is for education, and that class assignments have first priority. 2. Agree that the use of the Internet as part of our students’ educational experience is a privilege that should be taken seriously. Any inappropriate use of this resource may result in disciplinary action, loss of privileges, and/or legal action. 3. Agree not to participate in the transfer of inappropriate or illegal materials through the Athena Academy network. 4. Agree never to modify any computer on the Athena Academy network from its original configuration without the permission of the Network Administrator. 5. Agree never to delete, damage, move, change, or hack into files belonging to others. This includes file names. 6. Agree to follow procedures for using all school equipment such as computers, digital cameras, headphones, and microphones, etc. Any intentional damage will result in disciplinary action and the loss of technology privileges. 7. Agree that all damage to technology will be the financial responsibility of the students and their family. 8. Agree not to participate in any chat rooms, text messaging, or use of personal email accounts, unless approved by a teacher for the purpose of gaining access to files or material for use in school-related activities. 9. Agree that under no circumstances will I allow any other individual to use my account nor will I give anyone my password. System logins or accounts are to be used only by the authorized owner of the account. Users may not share or leave an open file unattended or unsupervised. Account owners are ultimately responsible for all activity under their account. 10. Agree to release Athena Academy from any liability or damages that may result from the inappropriate use of Internet connectivity on our campus. Furthermore, I will accept full responsibility and liability for the results of my actions with regard to use of the Internet at Athena Academy. 11. Agree that no use of the system shall serve to disrupt the operation of the system by others. System components including hardware or software shall not be destroyed, modified, or abused in any way. 12. Agree not to post any pictures taken of students, faculty, staff or other school persons, during school hours on the Internet, either from school or home. 13. Agree not to use computers, the Athena Academy network, or the Internet without an adult present in the room. 14. Agree that the school will monitor student computer activity. 15. I understand and will follow the rules of this agreement. I understand that any violation of the above rules may result in disciplinary action, the loss of my Internet/network privileges, and appropriate legal action. I also agree to report any misuse of the information to my teacher. Student Name (Please Print): _______________________________________________________ Student Signature: _______________________________________________________________ Parent Signature: ________________________________________________________________ Date: ____/____/________ Athena Academy Anti-Bullying Pledge – Students / Parents We, the students/parents of Athena Academy, agree to join together to stamp out bullying at our school. We believe that everybody should enjoy our school equally, and feel safe, secure and accepted regardless of color, race, gender, popularity, athletic ability, intelligence, religion and nationality. Bullying can be pushing, shoving, hitting, and spitting, as well as name calling, picking on, making fun of, laughing at, and excluding someone. Bullying causes pain and stress to victims and is never justified or excusable as “kids being kids,” “just teasing” or any other rationalization. The victim is never responsible for being a target of bullying. Student Pledge By signing this pledge, I agree to: 1. 2. 3. 4. 5. Value student differences and treat others with respect. Not become involved in bullying incidents or be a bully Be aware of the school’s policies and support systems with regard to bullying. Report honestly and immediately all incidents of bullying to a faculty member. Be alert in places around the school where there is less adult supervision such as bathrooms, corridors, and stairwells. 6. Support students who have been or are subjected to bullying. 7. Talk to teachers and parents about concerns and issues regarding bullying. 8. Work with other students and faculty, to help the school deal with bullying effectively. 9. Encourage teachers to discuss bullying issues in the classroom. 10. Provide a good role model for younger students and support them if bullying occurs. 11. Participate fully and contribute to assemblies dealing with bullying. I acknowledge that whether I am being a bully or see someone being bullied, if I don’t report or stop the bullying, I am just as guilty. Student Name (Please Print): _____________________________________________________ Student Signature: ______________________________________________________________ Date: ____/____/________ Parents Pledge By signing this pledge, we, the parents, agree to: 1. Keep ourselves and our children informed and aware of school bullying policies. 2. Work in partnership with the school to encourage positive behavior, valuing differences and promoting sensitivity to others. 3. Discuss regularly with their children their feelings about schoolwork, friendships and relationships. 4. Inform faculty of changes in their children’s behavior or circumstances at home that may change a child’s behavior at school. 5. Alert faculty if any bullying has occurred. 6. Cooperate with school staff if alerted that your child is bullying or is a victim of bullying. Parent Name (Please Print): _______________________________________________________ Parent Signature: _______________________________________________________________ Date: ____/____/________ Parent Name (Please Print): _______________________________________________________ Parent Signature: _______________________________________________________________ Date: ______/_____/_________ Athena Academy Photo Release Form Please read, sign and return the 1st day of school Permission to Use Student’s Photograph During the course of the academic year, Athena Academy may wish to use photographs of Athena Academy Students on school bulletin boards, in educational publications or in general media releases on a controlled basis. Any such photographs would highlight the student(s) either demonstrating learning techniques or participating in approved school activities. In accordance with school policy, names of individual students will not be released with any photographs. Student’s Name: ____________________________________ ____ I/We consent to the use of my child’s image; such use may include all Athena Academy Publications (print, online, video, etc.). Such photographs would highlight the students either demonstrating learning techniques or participating in approved school activities. Parent Signature _____________________________________________________________________ Date ____/____/________ Parent Signature _____________________________________________________________________ Date ____/____/________ Athena Academy Student Emergency Form Athena Academy student ID #: (year started/first initial/year born/last initial) Student’s full LEGAL Name: Birthdate: Nickname (if any): Gender: Street Address: Siblings at Athena Academy: City, State, Zip: Cell Phone: E-mail: Home Phone: Additional E-mail: Additional Phone: Relationship Mother Parents and other Responsible Guardian(s) for Student Daytime Location Name Day Phone Cell Phone Father In Case of Emergency Allergies: Dietary considerations: Current medications (including supplements): Medical Insurer: Physician: Dentist: Hospital of Choice: Policy #: Phone Number: Phone Number: Phone number: Email Emergency Contacts (Daycare Center/Sitter) Name Daytime Phone ***In the event you or any of the above persons cannot be reached, please specify your instructions for release of your child ___________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I/We hereby grant and delegate to the personnel of Athena Academy the authority and power in emergency situations to take any and all actions deemed necessary with regard to my/our child in securing medical attention or other necessaries for life, and I/We agree to be responsible for the cost thereof. In addition, I/We release Athena Academy from all liability on account of claims which me/us, or my/our child, may have arising out of my child's activity as a student at Athena Academy. I/We agree to indemnify Athena Academy for, and hold it harmless against any and all claims which may be made by me/us, my/our child, on behalf of my/our child, or against me/us or my/our child by reason of any occurrence during the course of my/our child's activity as a student at Athena Academy. With my signature below, I grant consent for Athena Academy staff to provide any and all necessary care for my child in the event of an emergency. Please mark the appropriate check-mark box to provide consent for the administration of the following: Yes No Aspirin Non-Aspirin Antacid Cough Drops Delsym 12 hour Parent Signature: ___________________________________________ Date: _____/_____/________ Parent Signature: ___________________________________________ Date: _____/_____/________ Athena Academy Vision and Hearing Name of Applicant: _______________________________________________________ Vision Results: Pass/Fail Date:__________________ Hearing Results Pass/Fail Date: _________________ Signature of Physician, Nurse, School Representative:____________________________ Athena Academy Immunization Records Please provide the School Office with a your child’s immunization record. This can be requested from your child’s physician. You are welcome to call with any question regarding this request: (650) 543-4560. You are welcome to also e-mail or fax this information to submit: [email protected] Fax: (650) 560-6473 Athena Academy Volunteer Driver Application Form School year ______________________ PLEASE NOTE: This form will not be processed if you do not attach a copy of the disclosure page from your current automobile liability insurance. If you wish to be placed on a list of volunteer drivers for Athena Academy for the current school year, please complete this form, attach a copy of your current automobile liability insurance coverage and forward to the School Manager at [email protected], or hand in at the front office. Name: Date of Birth: CA Driver’s License Number: __________________________________ Car 1 Make: Model: License Plate #: __________________________________ Car 2 Make: _______________________ Model: _____________________________ License Plate #: __________________________________ _______________________ _____________________________ Please complete the following questions: 1. Are you currently taking any medication that might impair or affect your ability to drive an automobile safely? Yes ______ No ______ 2. Does your medical history include any illnesses that might impair or affect your ability to drive an automobile safely? Yes ______ No ______ Please read the following statements and sign and date where indicated. 1. I understand that my driver’s license will be checked through the California Division of Motor Vehicles and that certain violations or a combination of violations and accidents as listed below may make me ineligible to serve as a volunteer driver. a. Two or more moving accidents in the last three (3) years regardless of fault. b. c. 2. Conviction of, prayer for judgment, or nolo contendere or any one of the following in the last five (5) years: DWI; hit and run involving bodily injury; manslaughter; driving with a suspended license. Conviction of, prayer for judgment, or nolo contendere of three (3) or more speeding tickets in the last three (3) years. I agree to provide a copy of my current automobile liability insurance coverage reflecting a minimum level of $100,000/$300,000. _______________________________________________ ____/____/________ Volunteer’s Signature Date Athena Academy Walking Field Trip Waiver Form In order to cut down on the notices sent home during the school year, this will enable your child(ren) to take part in the various walking field trips/off-campus activities planned by the teachers throughout the year. Teachers and support staff may take students on walking field trips to enrich and complement their educational experience. Such trips are always under the supervision of at least one teacher and/or school administrator, or certified athletic coach in the case of a same day athletic event, and all precautions are taken to ensure each student’s welfare. The student(s) will not bring home any additional permission slips unless the trip involves more than walking off campus, other special circumstances, or overnight activities. Field trips/off-campus activities will only involve walking distance events. I (We) have read and understand the above walking field trip/off-campus activities notice. My (Our) child(ren) is/are authorized to attend any school sponsored field trips/off-campus activities. Parent Signature: ___________________________________________________________ Date: _____/_____/________ Parent Signature: ___________________________________________________________ Date: ____/_____/________