Allenstown Elementary 30 Main Street Allenstown, NH 03275 Phone: 485-9574 Fax: 485- 1805

Armand R. Dupont School 10 ½ School Street Allenstown, NH 03275 Phone: 485-4474 Fax: 485- 1806

Anthony Blinn, Principal, Allenstown Elementary School Mark Dangora, Principal, Armand R. Dupont School Kathleen Murphy, District Special Education Coordinator

Dear Parent and/or Guardian: Welcome to the Allenstown School District. Before your child(ren) will be allowed to attend school, the following information is required: 1. A copy of your child’s immunizations, as well as a current, physical exam (within the past one year) 2. A copy of your child’s birth certificate 3. Proof of residency (lease/rent agreement or utility bill – ie: phone, cable, electricity, water). 4. Proof of legal guardianship may also be required which supports residency in Allenstown.

School Hours: AES 8:10-2:30 ARD 8:00-2:22 Before/After-school program: Please contact Kelli Bassett from Peace of Mind at 603-848-8499 for more information. Allenstown School District: You can access the school calendar, supply lists, and many other important items by visiting our website. https://sites.google.com/a/sau53.org/allenstownschools/Home

PLEASE DO NOT TEAR PACKET APART. PLEASE FILL OUT COMPLETELY, SIGN AND DATE WHERE INDICATED, AND RETURN BACK TO THE SCHOOL.

Allenstown Elementary 30 Main Street ANH 03275 Allenstown, Phone: 485-9574 Fax: 485- 1805

Armand R. Dupont School 10 ½ School Street Allenstown, NH 03275 Phone: 485-4474 Fax: 485- 1806

Anthony Blinn, Principal, Allenstown Elementary School Mark Dangora, Principal, Armand R. Dupont School Kathleen Murphy, District Special Education Coordinator

AUTHORIZATION TO RELEASE STUDENT RECORDS Records to be obtained from: Previous School Name: Address: City/State/Zip

_____

Phone #____________________ Fax # ____________________

(Student’s Name)

(Birth Date)

(Parent/Legal Guardian’s Name)

(Grade) (Phone #)

Type of Material: (Check all that apply) ___ FAX NH SASID # ___ School Record ___ Student Medical Record ___ Individual Education Plan (IEP) ___ Special Education Team Minutes

___ Psychological Report ___ Educational Evaluation Reports ___ Vision and Hearing Tests ___ Medical Treatment ___ Other _____________________

I have read or have had read to me, the above information. I understand the purpose for the release of information and records, to whom the information records are to be released. I understand and agree to this statement. ___ I hereby authorize Allenstown School District to obtain pertinent information concerning the above named student(s). OR ___ I hereby authorize Allenstown School District to release pertinent information concerning the above named student(s).

___________________________________________________________ Signature of Parent/Guardian Date

Allenstown School District New Student Registration STUDENT INFORMATION

MMS ID#

SASID#

ENTRANCE DATE:

Student Name:_______________________________________________ Grade Entering:______ Date of Birth:_____/_____/______ Last

First

Middle

City of Birth:______________________________ State of Birth:_______

Gender:  M  F

Date of Withdrawal:_____________

Previous School:________________________________________________________________________ Grade Last Attended:_____ Name of School

City

State

Has your child ever registered or been evaluated by Allenstown School District before?  Yes  No If yes, when, or how long ago?___________________________________________________________________________________ Does your child receive Special Services now? If yes, check all that apply:  IEP  504  PT  OT  Speech  Vison  Special Transportation  Counseling  Other ____________________________________________________________________

RESIDENCY AFFIDAVIT (Circle One) Primary Parent / Legal Guardian Name:__________________________________________________________________ Last

First

Middle

_______________________________________________________________________________________________________________________________________ Street Address City State Zip Code

The McKinney-Vento Homeless Education Assistance Improvements Act 42 U.S.C. 11435 was enacted to ensure that homeless children and youths have access to the same public educational opportunities that non-homeless students enjoy. In order to better serve the needs of our students and their families, Allenstown School District is attempting to identify homeless children and youth within its boundaries by asking families to answer the following residency questions. By answering the questions below, we will be able to provide the appropriate services to those families in need of assistance. 1. 2.

Is your current address a temporary living arrangement?  Yes  No Is this temporary living arrangement due to loss of housing or economic hardship?  Yes  No

If you answered YES to the above questions, please check only one box that best describes where the STUDENT is presently living:  In a shelter

 In a motel

 In a car, park, campsite

 Student is temporarily housed, awaiting foster care placement

 Temporarily living with another family (relatives or friends) in a house, mobile home, or apartment due to lack of housing

ETHNICITY AND RACE Ethnicity: Is this student Hispanic/Latino? (Choose only one)  No, not Hispanic/Latino  Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Race: No matter what you selected above, please check all that apply below:  American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America {including Central America}, and who maintains tribal affiliation or community attachments.)  Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam.)  Black or African American (A person having origins in any of the black racial groups of Africa.)  White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)  Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

HOME LANGUAGE SURVEY Student Information First name:

Last name:

Date of Birth:

Gender:

□ female □ male Country of Birth:

Date first enrolled in a U.S. school: Month_____ Year_______

Current grade:

Family Information Name of parent/legal guardian:

Phone number:

Address:

□ Please translate school notices. Language_________________

Questions for Parents/Guardians

Response

Please list all languages spoken in your home. Which language did your child first hear or speak? If English is the only language listed, stop here. If another language is listed, please answer the rest of the questions. Which language(s) do you speak to your child? Which language(s) does your child speak at home with adults? Which language(s) does your child speak at home with other children? For parents and guardians: If a language other than English is listed above, an ESOL teacher will test your child to find out if he or she can speak, understand, read, and write well in English. The results will be sent to you within 30 days. Based on the results of the test, your child may be eligible to enroll in an English language (ESOL) class at school. Parents/guardians may accept or decline ESOL program services for their child. Instructions for survey administrator: 1. Please provide an interpreter when necessary. 2. If responses indicate a language other than English, please contact the ESOL teacher and provide her/him with a copy of this survey. Date of referral to ESOL teacher: ________________ 3. File original Home Language Survey in student’s cumulative folder.

EDUCATIONAL EXPERIENCE FORM: BIRTH – SIX YEARS OLD

Please check only one for each year indicating the major portion of the year your child spent in that particular educational or home setting.

BIRTH – YEAR 1  Home Care  Day Care  Babysitter  Play Group  Nursery Group  Kindergarten  Other Explain: ________________________

YEAR 1 – YEAR 2  Home Care  Day Care  Babysitter  Play Group  Nursery Group  Kindergarten  Other Explain: ________________________

YEAR 2 – YEAR 3  Home Care  Day Care  Babysitter  Play Group  Nursery Group  Kindergarten  Other Explain: ________________________

YEAR 3 – YEAR 4  Home Care  Day Care  Babysitter  Play Group  Nursery Group  Kindergarten  Other Explain: ________________________

YEAR 4 – YEAR 5  Home Care  Day Care  Babysitter  Play Group  Nursery Group  Kindergarten  Other Explain: ________________________

YEAR 5 – YEAR 6  Home Care  Day Care  Babysitter  Play Group  Nursery Group  Kindergarten  Other Explain: ________________________

PARENT QUESTIONNAIRE Child’s Nickname:__________________________________________ 1. Check the word(s) that apply to your child: □ Cooperative □ Aggressive □ Shy □ Happy □ Inquisitive □ Independent □ Attentive □ Dependent □ Tense □ Outgoing □ Agreeable □ Flexible □ Helpful □ Stubborn □ Demanding □ Talkative □ Worried □ Considerate □ Self-Centered □ Responsible 2. Is your child able to answer the phone? □ Yes □ No 3. Does your child initiate conversations with children whom she/he does not know? □ Yes □ No 4. Does your child enjoy talking with adults whom she/he does not know? □ Yes □ No 5. Does your child like to color? □ Yes □ No 6. Would she/he prefer using a coloring book or drawing and coloring her/his own pictures? □ Yes □ No 7. Can your child button, snap or zip her/his clothes without your assistance? □ Yes □ No 8. Can your child go to the bathroom without your assistance? □ Yes □ No 9. Can your child put puzzles together? □ Yes □ No 10. Can your child cut with scissors? □ Yes □ No 11. What outdoor activities does your child enjoy? ________________________________________________________ 12. Does your child like listening to a story? □ Yes □ No 13. How long can she/he be attentive to the story? _______________________________________________________ 14. How many times a week do you read to your child? _____________________________________________________ 15. Does your child read? □ Yes □ No 16. What can she/he read? ___________________________________________________________________________ 17. How many hours of TV do your watch per day? ________________________________________________________ 18. What are your child’s favorite TV shows? _____________________________________________________________ 19. What are your child’s favorite indoor activities? _______________________________________________________ 20. Would your child rather play by her/himself or with other children? _______________________________________ 21. Does your child enjoy the company of adults? □ Yes □ No 22. Can your child follow a two-step direction? □ Yes □ No 23. Does your child complete a task without being reminded? □ Yes □ No 24. Does your child have any jobs to complete at home? □ Yes □ No If yes, list: ______________________________________________________________________________________ 25. Does your child have a pet? □ Yes □ No What kind and name? ____________________________________________________________________________ 26. Does your child have a good friend who will be coming to our school? □ Yes □ No List names please: _______________________________________________________________________________ 27. Is there any other information about your child that you feel we should know? ______________________________ _______________________________________________________________________________________________

*** CERTIFICATION STATEMENT – SIGNATURE REQUIRED *** All of the information on this form is important for safety purposes; for state reporting purposes; and for the determination of where a student is entitled to attend school tuition-free. Under penalty of unsworn certification - RSA 641:3 – I declare that the information on this form is correct. I will promptly notify the school of any changes in the information on this form. __________________________________________________________________________

______________________________________________________

Signature of Parent / Legal Guardian

Date

ADDITIONAL REGISTRATION FORMS

SAU 53 Emergency Form

__ AES __ ARD Year 20____-20____

Student Date of Birth: ___/___/___ Last Name: ____________________________________________________ Grade Entering ____ Homeroom ____ First Name: ____________________________________________________ Walker: (Y) (N) Street Address: _________________________________________________ Bus Color: ___________ City: ____________________________ State______ Zip ________________ Contact 2: Contact 1: Primary Parent/Legal Guardian (circle one): Mother Father Step Parent Guardian (circle one) Full Name: ________________________________________ Has custody: (Y) (N) Can pick-up/dismiss: (Y) (N) Street Address: ____________________________________ Full Name: _____________________________________ Cell Phone (_____) __________________________________ Street Address: _________________________________ Home Phone (_____) ________________________________ Cell Phone (_____) ______________________________ Work Phone (____) _________________________________ Home Phone (_____) ____________________________ Email Address: _____________________________________ Work Phone (____) ______________________________ Employer: _________________________________________ Email Address: __________________________________ Contact 3: Contact 4: Mother Father Step Parent Guardian (circle one) Mother Father Step Parent Guardian (circle one) Has custody: (Y) (N) Can pick-up/dismiss: (Y) (N) Has custody: (Y) (N) Can pick-up/dismiss: (Y) (N) Full Name: ________________________________________

Full Name: _____________________________________

Street Address: ____________________________________

Street Address: _________________________________

Cell Phone (_____) __________________________________

Cell Phone (_____) ______________________________

Home Phone (_____) ________________________________

Home Phone (_____) ____________________________

Work Phone (____) _________________________________

Work Phone (____) ______________________________

Email Address: _____________________________________

Email Address: __________________________________

Marital Status Mother: ___ Single ___Married ___ Separated ___ Divorced ___ Deceased ___ Remarried Marital Status Father: ___ Single ___Married ___ Separated ___ Divorced ___ Deceased ___ Remarried Student Lives with: ___ both parents ___ Mother ___ Father ___ Guardian Are there any court documents in existence regarding custody/legal guardianship? ____ Yes ____ No ***Court Documents declaring custody/guardianship must be on file with the school.*** Other Children in the Family: Full Name: _____________________________________________________ Sex: F M D.O.B. ___/___/___ Grade: ___ Full Name: _____________________________________________________ Sex: F M D.O.B. ___/___/___ Grade: ___ Full Name: _____________________________________________________ Sex: F M D.O.B. ___/___/___ Grade: ___ Please list Emergency Contact that will be available if you and other contacts listed above cannot be reached. Emergency Contact: _____________________________________________ Home Phone: (____)___________________ Address: ________________________________ Relationship: ____________ Cell Phone (____)____________________ Emergency Contact: _____________________________________________ Home Phone: (____)___________________ Address: ________________________________ Relationship: ____________ Cell Phone (____)____________________

Primary Parent/Legal Guardian Signature: _________________________________ Date: ______________ Revised March 2017

SAU53 Annual Health History Student Last Name: _____________________________ First Name: ________________________ Grade: ____ Student’s Doctor: Name: ________________________________________________________ Phone: ______________________________ Street Address: _________________________________________________ City/Town: __________________________ Student’s Dentist: Name: ________________________________________________________ Phone: ______________________________ Street Address: _________________________________________________ City/Town: __________________________ Please indicate any allergies your child may have: Food: ___________________________________________ Medicine: _________________________________________ Seasonal: ________________________________________ Other: ____________________________________________ Please check if your child has any health conditions or concerns with the following: ____ ADD/ADHD

____ Concussions

____ Hernia

____ Skin

____ Asthma

____ Diabetes

____ Pneumonia

____ Stomach

____ Bee Sting

____ Ear Infections

____ Scoliosis

____ Strep Infections

____ Bleeding Disorders

____ Ear Tubes

____ Seizures

____ Surgery

____ Bones/Joints

____ Headaches

____ Serious Injury

____ Other

____ Bronchitis

____ Heart Problems

____ Sinus

Please explain any items checked: ______________________________________________________________________ __________________________________________________________________________________________________ Has your child had any injury, serious illness, or hospitalization the past year? (Y) (N) If yes, date(s): ____/____/____ Reason: ___________________________________________________________________________________________ Has your child had any difficulty with: _____ Speech _____ Hearing _____Wears Device Does your child wear glasses? (Y) (N) Contacts: (Y) (N) Does your child have any physical limitations that would prevent participation in any activities at home or school? (Y) (N) If yes, explain: ______________________________________________________________________________________ Please list any medication that your child takes on a regular basis; at home or in school. Medication Name:

Dose/Frequency:

Reason:

Dose/Frequency:

Reason:

Dose/Frequency:

Reason:

I authorize the school nurse to provide emergency care for the health/safety of my child. I understand that the school will not assume responsibility for expenses incurred. I give permission for the school nurse to share pertinent health information about my child with appropriate school/EMS personnel on the “need-to-know” basis.

Signature of Parent/Legal Guardian: _______________________________________ Date: ______________ Approved: July 2, 2013; Revised March 2017

SAU #53 ALLENSTOWN SCHOOL DISTRICT SCHOOL HEALTH SERVICES TO STUDENTS State law requires that all children, prior to entering kindergarten or first grade, shall have had certain immunizations. The statutes further require that there be a complete physical examination. Local policy states that this physical examination shall have been performed within twelve months prior to the date of entry into the school system. The health of each student greatly influences his ability to learn. THE NEW HAMPSHIRE LAW REQUIRES: RSA 200:32

A complete medical examination by a licensed physician upon or prior to entrance into the public school system and thereafter as often as deemed necessary by the local school authority.

RSA 200:38-1

The immunizations listed below must be completed prior to school entrance. 1. Measles Vaccine (live-attenuated) (Having the measles is acceptable when verified) 2. Oral Trivalent Polio Vaccine (Sabin) 3. Diphtheria, Pertussis, and Tetanus (DPT) (Adult type TD when over 6 years of age) 4. Rubella Vaccine 5. Mumps Vaccine 6. Hepatitis B (for students born after 1/1/93) 7. Varicella Vaccine

Please complete both sides of this form and take to your physician at the time of examination or provide an electronic physical and immunizations from your physician. Name _____________________________________ School _______________________ Grade __________ Date of Birth ________________________________ Place of Birth __________________________________ Address _________________________________________________________________________________ Name of Parent/Guardian ___________________________________________________________________ Name of Physician ________________________________________________________________________ Health History: Allergy ___________________________________ Asthma __________________________________ Chicken Pox ______________________________ Diabetes _________________________________ Ear Infections _____________________________ Heart Disease _____________________________ Mumps __________________________________

Operations _______________________________ Serious Injuries ____________________________ Strep Throat ______________________________ Tuberculosis or Contact _____________________ Convulsions ______________________________ Other ____________________________________

Does your child have any physical or emotional problem? Explain ___________________________________ Is your child on any kind of medication? Explain _________________________________________________ Do you have any handicap children living in your home? Explain ____________________________________

ALLENSTOWN SCHOOL DISTRICT NAME OF PUPIL __________________________________________ DATE OF BIRTH _________________ PHYSICAL EXAMINATION: Height: ___________________ Weight: __________________ Eyes: ____________________ Skin: _____________________ Ears: ____________________ Nose/Throat: ______________

Glands: __________________ Lungs: ___________________ Heart: ____________________ Hernia: ___________________ Abdomen: ________________

Nervous System: ___________ (Specify Epilepsy) Orthopedic: _______________ Allergies: _________________ Urine: ____________________ Hematology: ______________

Recommendations: ________________________________________________________________________

This child is physically capable of carrying on a full academic and physical education program: □ Yes □ No Exceptions: (Explain) ______________________________________________________________________ Physician: (Signature) ______________________________________________________________________ Date of Examination: _______________________________________________________________________ HEALTH HISTORY: Dates (Month/Day/Year) Hepatitis B - 3 required (for students born after 1/1/93 DPT Series – 5 required Polio Series – 4 required MMR – 2 required TB tine Varicella (2 dose) Chicken Pox Other TO PARENTS: Please send this completed form to school nurse by August 15th prior to your child entering school. If you are unable to complete the required immunization and physical by the first day of school, please notify the school nurse.

Student’s Name: ___________________________________________ Grade/Class: _____________________

PERMISSION FOR GIVING OVER-THE-COUNTER MEDICATIONS ** Your child CANNOT be given any over the counter medications in the health office UNTIL we have received this form. ** These treatments would be dispensed as directed. Please check off any of the following medications, which may be given to your child in the school health office.       

Antacid / Tums Antibiotic Ointments / Bacitracin / Neosporin (for cuts) Benadryl (for allergic reactions/hivesa) Caladryl Clear Lotion (for poison ivy/bug bites) Cough Drops Hydrocortisone Cream (for rashes/dermatitis) Lip Balm / Petroleum Jelly

PLEASE NOTE: The above supplies may not be supplied by the health office. If you would like these or other types of medication given at any time to your child, you must complete the Administration of Medication Form, and you may be asked to bring a supply of medicine in a manufacture labeled container. Only adults can transport medication to and from school.

ADMINISTRATION OF OVER-THE-COUNTER MEDICATION I hereby instruct the designated member of the school staff to assist my child, named above, in taking (medication) ________________________________________ (dosage) ____________________ (route: orally, topically) ____________________ at (time of day) ____________________ for (duration/how long?) ____________________ for (condition) _________________________________________________________. I hereby request and give my permission for a designated member of the school staff to assist my child, named above, in taking the medication, and I release said person from responsibility for any adverse effects from the medication or from the effects when my child refuses to cooperate in taking said medication.

NOTE: This form is to be used for parental permission for administration and permission for giving of overthe-counter nonprescription medications. A hand written note is an acceptable substitute for this form, but the note MUST contain all the information requested above. Print Name of Parent or Guardian: _____________________________________________________________ Home Phone Number: ____________________

Work Phone Number: ____________________

Signature of Parent or Guardian: _____________________________________

Date: __________________

***MEDICATION MUST BE IN ORIGINAL MANUFACTURER’S PACKAGE AND HAVE ORIGINAL LABEL. NO OTHER SUBSTITUTES WILL BE ALLOWED.***

ALLENSTOWN SCHOOL DISTRICT WALKER/BUS REGISTRATION FORM Dail Transportation Coordinator: Linda Beaudoin Contact Number: 603-736-9682

Student Name:__________________________________________ Grade__________ Home Street Address: ___________________________________________________

AM Mode To School (Check all that apply):  Bus Bus Stop: __________________________ Bus Color: _______________  Walker

PM Mode To Home (Check all that apply):  Bus Bus Stop: __________________________ Bus Color: _______________  AES After School Program  Boys & Girls Club  Walker

Parent/Guardian:________________________________________________________ Telephone (Home):___________ Work:______________ Cell:_________________ E-Mail Address:_________________________________________________________

If attending Boys & Girls Club: Days Attending Please Circle:

M T W Th F

If attending AES After School Program: Days Attending Please Circle: M T W Th F

If you need to make any changes please ask for a new walker/bus form to be sent home with your child. The form can be returned by your child the next day.

Parent Signature:_______________________________________Date:____________

Student Name: ________________________________ Grade: ______ ONE CALL NOW _____ (Initial) We use the One Call Now Emergency Notification Service, which allows us to send a telephone or e-mail message to notify you of school delays or cancellations due to inclement weather and remind you about various events, including report card distribution, open house, field trips, and more. Please make sure you provide the school with the most current contact and e-mail information for the primary contact. FIELD TRIP _____ (Initial) Permission is hereby given for my child to participate in all school-sponsored field trips during the current school year. It is understood that specific information pertaining to each trip will be sent home before each scheduled trip. INTERNET/COMPUTER POLICY The student and parent/guardian agree that the student will abide by the guidelines set forth in the Allenstown School District Internet/Computer Policy I understand that it is a privilege to use school computers and I will act accordingly. 1. I will obey all school rules and act responsibly. 2. I will only use technology/computer equipment with teacher permission. 3. I will use the programs and equipment only as directed by the teacher. 4. I will only send or receive anything over the computer that is approved by the school. 5. I will respect the property, content, and privacy of other students/users. 6. I will keep my real name, address, and phone number private on the internet. 7. I will only print from the computer with teacher permission. 8. Only after teacher permission will I “Share” Google documents. 9. I will respect blocked pages and security systems. 10. I will respect the work of others, and only log into my own account. 11. I will only say appropriate things to others on the internet/computer. 12. I will alert the teacher right away if there is a problem, or something inappropriate happens. 13. I understand that the supervising teacher/adult has the right to limit access. 14. I understand that the use of individual accounts is at the discretion of the supervising teacher. *If a student breaks these rules, computer privileges may be taken away for a period of time. _____ (Initial) I AGREE to abide by all the rules pertaining to the Internet/Computer Policy as outlined in the Student/Parent Handbook. ALLENSTOWN SCHOOL DISTRICT STUDENT/PARENT HANDBOOK The Allenstown School District Student/Parent Handbook is available on-line by visiting our district website at www.sau53.org/allenstown. _____ (Initial) We have reviewed the school policies and procedures outlined in The Allenstown School District Student/Parent Handbook by accessing it on line. My child and I are committed to a successful and productive school year and we will make every effort to work together with school faculty and staff toward that goal. □ I am unable to access The Allenstown School District Student/Parent Handbook on-line and request that a paper copy be sent home. Once I receive it, my child and I are committed to a successful and productive school year and we will make every effort to work together with school faculty and staff toward that goal.

GOOGLE APPS FOR EDUCATION/AND OTHER ONLINE SERVICES The Allenstown School District has deployed Google Apps for Education for all students. Google Apps for Education is an online service which allows students to create and store documents, access information, study, and collaborate with students and teachers. Students can access Google Apps for Education while at school, but students can also access it from outside of school from wherever they have an internet connection. This service necessitates an email address for each student for login purposes. This login can be used to access online services 24 hours a day. District policy restricts use to educational purposes. Students are expected to abide by that policy. Deploying this service allows us to introduce concepts around digital citizenship and how to cultivate good habits as they relate to email accounts and document storage/sharing. The Allenstown School District Acceptable Use\Computer Policy applies to the use of these accounts. In order for us to provide your student with the most effective web-based tools and applications for learning, we need to abide by federal regulations that require a parental signature. In order for students to use some online programs and services, certain personal identifying information, generally the student’s name and email address, must be provided to the web site. Under federal law, these sites must provide parental notification and obtain parental consent before collecting personal information from children under the age of 13. The law permits schools to consent to the collection of personal information on behalf of all of its students, thereby eliminating the need for individual parental consent given directly to the web site operator. This form will constitute consent for the Allenstown School District to provide ONLY this personal identifying information for your child consisting of student first name, last name, email address to the web operators of educational programs and services used in the classroom. _____ (Initial) Permission is hereby given for my child to have access to Google Apps For Education and other online services as outlined in the Student/Parent Handbook. STUDENT MEDIA CONSENT AND RELEASE FORM Throughout the school year, students may be highlighted in efforts to promote Allenstown School District activities and achievements. For example, students may be featured in materials to train teachers and/or increase public awareness of our schools through newspapers, radio, TV, the web, DVDs, displays, brochures, and other types of media. I hereby give Allenstown School District and its employees, representatives, and authorized media organizations permission to print, photograph, record, and published of name of my child for use in audio, video, film, or any other electronic, digital and printed media. a) This is with the understanding that neither Allenstown School District nor its representatives will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation. b) I further release and relieve Allenstown School District, its Board of Trustees, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material.

□ Yes, I give permission.

□ No, I do not give permission. _____ (Initial) I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions.

This release will remain in effect for the Allenstown School District, unless a change is requested or initiated, in writing, by the parent or legal guardian.

Student’s Signature_________________________________________________________ Date_________________________ Parent/Guardian’s Signature____________________________________________ Date_________________________