Welcome to Orchard Lake Middle School!

Student documentation required to register in the West Bloomfield School District:    

Certified copy of the student’s birth certificate with raised seal, or Affidavit of Birth with copy of passport or other birth record. Immunization record or waiver. Last report card from previous school. When applicable, judgement of divorce or custody order.

Residency documentation required to register in the West Bloomfield School District:  

If you purchased a home, you will need closing/settlement papers OR principal residency exemption affidavit OR property transfer affidavit stamped by the township. If you are leasing your home, you will need a signed lease/rental agreement showing dates showing term occupancy and names of those residing in the home.

PLUS: 

Current gas bill and electric bill with current name and address. If you have not yet received a bill, please bring proof of activation as a placeholder. You may then send copies of the bills once you received them.

If the parent is residing with another person on the deed/lease:   

A “Verification of Residency Affidavit” must be completed. The residency documentation required for owning/leasing in that person’s name as listed above plus gas and electric bills in that person’s name. A driver’s license and two bills/proof of insurance/pay stubs/etc. in the parent’s name.

Other documentation may be requested by the district as needed. If you have any questions, please feel free to contact me. [email protected] Phone: 248-865-4480 Fax: 248-865-4481

Orchard Lake Middle School 6000 Orchard Lake Road West Bloomfield, MI 48322

For Office Use Birth Certificate Verified______ Immunization Records_____

WEST BLOOMFIELD SCHOOL DISTRICT

Homeroom Teacher/Number___________________________

Student Registration Form 1 of 3

Student Number_______________________

For Office Use

Counselor___________________________________________

Grade_________________________________________

Date of Records Requested_________________

Date of Records Received________________

Start Date_________________________________ Schools of Choice/Resident District____________________

Year of Graduation ______________

New Enrollee

Re-enrollee – Student has previously been enrolled in West Bloomfield School District or a District preschool program. Student is currently taking on-line classes through another school district

Student’s Name _____________________________________________________________________ Last

First

Male

Female

Middle

Student’s Address _____________________________________________________________________________________ Street, Apt. No.

Home Phone No. ______________________

City

Listed

Zip Code

Unlisted

Date of Birth ___________________ Place of Birth (City, State)____________________ Country____________________ Former School ________________________________ Private __ Public __ Grade Last Completed ___ Date __________ Former School Address ___________________________________City/State _________________________ Zip _________ (State Requirement) Multiple Birth Order- (To complete when children of multiple births

Born

First,

Second,

Third,

Fourth, etc.

have identical first, middle, and last names.)

As required by the U.S. Dept. of Education: Ethnicity: Hispanic/Latino Yes (Please continue to answer the following Choose one or more race) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

For office use Program Enrollment/Eligibility (Y/N/D) Title 1 _____ Career & Tech Voc _____ Migrant Education _____

Rev. 3/15

No

_____ _____ _____ _____ _____

Does your child speak English? Yes No What is the primary language spoken at home? ______________________________________________ If applicable, date entered USA_____________________

Special Education Gifted and Talented Adult Education

_____ _____ _____

Early Intervention Limited Eng Proficient Section 504

_____ _____ _____

Side 2 of 3

INFORMATION Please include first and last name

Father

Mother

Court appointed full guardianship Yes No

Court appointed full guardianship Yes No

Adult with whom student resides if not a Name: parent (include first and last name)

Name:

Relationship:

Relationship:

Court appointed:

Yes

No

Court appointed:

Yes

No

Employer & Address (Include Street Number & Name, (Apt. Number), City, State, Zip Code) Other contact numbers(include area codes) Business Phone 1. Pager Number 2.

1. 2.

Cell Phone Number 3. Email Address 4.

3. 4.

PARENT LIVING ELSEWHERE INFO Send Mail? Name (Last, First, Middle)

Yes

No

Relationship to student Address

Street: ______________________________________________________ Apartment Number:____________________________________________ City: ________________________________________________________ State: _______________________________________________________ Zip Code: ___________________________________________________

Please list other children in family: Name

Birth Date

School Enrolling at

__________________________________________

__________________

______________________________

__________________________________________

__________________

______________________________

__________________________________________

__________________

______________________________

__________________________________________

__________________

______________________________

Rev. 3/15

Side 3 of 3

EMERGENCY INFORMATION - At a later date you could receive additional forms requesting similar information for you to complete. Emergency Contacts - Please list names, other than parents/guardians, to contact in case of illness/emergency. 1. ______________________________________

____________________________

Name

2. ______________________________________

Relationship

3. ______________________________________

Telephone with area code

____________________________

Name

Relationship

Relationship

______________________ Telephone with area code

____________________________

Name

______________________

______________________ Telephone with area code

Please coordinate administration of medication with the school office. Students at the middle and high school level are permitted to carry and administer medication with proper authorization from a parent and physician. Elementary students are permitted to carry and administer medication when the privilege is a part of an Individualized Education Program (IEP) or Section 504 Plan and the parent provides written consent and proper authorization from the physician. This privilege may, if abused, be revoked by the building principal. HEALTH INFORMATION - Does your child have any specific health problems? If so, please explain and alert the school of any necessary emergency actions needed.

____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Your Child’s Doctor’s Name ____________________________________ Telephone _______________________________ area code and number

In case of emergency, is there a hospital preference? __________________________________________________________ In case of extreme emergency, the school authorities have my permission to take such action, as they deem necessary. Signed: _____________________________________________________

Date:______________________________

I affirm that, as the parent/legal guardian, all information provided in this document is true and accurate, and that my child and I reside at the listed address. The undersigned understands that documented and verifiable proof of residency is required and it is his/her responsibility to inform the appropriate school office if and when any of the information set in this form changes. West Bloomfield School District will refer matters of residency violations/residency fraud to the applicable local police department and/or Oakland county prosecutor. The undersigned also affirms that the enrollee has not been expelled from any Michigan school district prior to seeking enrollment in the West Bloomfield School District. Primary email address for District Power Announcements: Primary phone number for District Power Announcements: Parent Signature:

Rev. 3/15

Today’s Date:

West Bloomfield School District Request for Records of Incoming Student Student Name__________________________________________________________________ Last

First

Birthdate________________________ Grade______

Middle

Month last attended_________20____

I give my permission for______________________________________________ Name of Previous School

______________________________________________ Address

______________________________________________ City, State, Zip

to release the following to _______________________ School: ORCHARD LAKE MIDDLE SCHOOL UIC Code Graduation/enrollment dates Scholastic records (If numerical grading is used, please send letter grade equivalent.) Standardized test results Attendance records Health records Psychological tests Discipline Records Other_______________________________________________________ Reason for request_______________________________________________________________ Send to:

ORCHARD LAKE MIDDLE SCHOOL ATTN: RECORDS 6000 ORCHARD LAKE ROAD WEST BLOOMFIELD, MI 48322 P: 248-865-4480 FAX: 248-865-448

Phone:

_________________________ Date

_________________________________________ Signature of Parent/Guardian or Student (if 18 years or older)

WEST BLOOMFIELD SCHOOL DISTRICT Request for Discipline Records of Incoming Student

Student Name_____________________________________________________________________ Last

First

Middle

Date of Birth______________________________________

 

The undersigned affirms that the student known as _________________________________ has not been suspended or expelled, or is not pending suspension/expulsion, from any public or private school. The undersigned affirms that the student known as _________________________________ has been suspended, expelled or is pending suspension/expulsion from any public or private school.

Has the student ever been convicted of a felony?

 Yes

 No

Explain the circumstances in detail. For suspension or expulsion include the school name(s), date(s) of suspension or expulsion, and a description of the incident(s).

(Use reverse side if additional space is needed.) I give my permission for the following schools from the previous two years to release and/or communicate any and all discipline records to West Bloomfield School District for the student named above. If home schooled, last school attended.

Name of Current School

Name of Previous School (if needed)

Address

Address

City, State, Zip

City, State, Zip

Dates Attended

Dates Attended (List additional schools on reverse side.)

___________________

_________________________________________________________________

Date

Signature of Parent/Guardian or Student (if 18 years or older)

__________________________________________________________________________________________ SENDING SCHOOL: PLEASE CHECK ONE





According to our records, the information provided by parent/guardian on the above named student is correct. According to our records, the information provided by parent/guardian on the above named student is not correct.

Name of School , Phone #

Signature, Title

RETURN TO: ORCHARD LAKE MIDDLE SCHOOL SCHOOL: ATTN: RECORDS ADDRESS: 6000 ORCHARD LAKE ROAD PHONE:

WEST BLOOMFIELD, MI 48322 P: 248-865-4480 FAX: 248-865-448 5/11

Date

FAX:

ORCHARD LAKE MIDDLE SCHOOL COUNSELING DEPARTMENT NEW STUDENT INFORMATION NAME:______________________________________________________________________________ (Last) (First) (M.I.) Grade Date Any health problems? (hearing, vision, allergies, seizures etc.) If yes, please specify:_________________________________

YES

NO

Any medication taken at school? YES NO If yes, please specify:_________________________________ Please list any social or emotional concerns that may affect your child's academic performance or

adjustment to his/her new school: Has your child received Special Education Services in the past?

YES

NO

If yes, please check services received: _____Speech & Language _____Social Work _____ESL (English as Second Language) _____504 _____Special Education _____Learning Disability :___________________________ _____Emotionally Impaired _____Other Health Impairment (please specify):_______________________ _____Cognitively Impaired _____Autism Spectrum Disorder _____Other (please specify):___________________________

Does your child have a current IEP (within the last school year)? YES NO (If yes, please bring a copy of the most recent IEP on your orientation day. You may drop the IEP off in the main office to Mrs. Carla Jones.) Has he/she been diagnosed with ADD or ADHD? YES NO If yes, is he/she on medication? YES NO Type of medication:________________________________________ What strategies have been helpful in school?______________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Has your child ever been in any advanced or gifted classes? YES NO If yes, what subject areas?____________________________________________________ (If math, be sure to take the advanced math placement test.) What is your child's best subject area?___________________________________________ What is the most difficult subject for your child?____________________________________ Please list your child's interests outside of school___________________________________

West Bloomfield School District HOME LANGUAGE SURVEY

Student Name Last:______________________________ First:______________________________ 1. Is your child's native tongue (first language) a language other than English? Yes__ No__ What is that language?__________________________ 2. Is the main language* used in your child's home a language other than English? Yes__ No__ What is that language?__________________________ * The "main language" means the dominant language used by a person for communication.

Note to building administrative assistants: Please give this form to your building ESL teacher/coordinator at the time of registration to comply with required registration procedures. Thank you. Revised 2-09

WEST BLOOMFIELD SCHOOL DISTRICT Student Pledge Bully-free School Zone

We the students of the West Bloomfield School District say... "At this school district, we believe…we should be... bully free!"

Bullying defined is when one individual (or group) seeks to dominate, control, intimidate, and/or terrorize the life of another individual. We know bullying can be pushing, shoving, hitting, and spitting, as well as name-calling, picking-on, making fun of, laughing at, and/or 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. Bullying behavior is not welcome at our school. Everyone in the West Bloomfield School District will work to provide a school environment that is safe, calm, orderly, procedural, and one in which people care for one another. By signing this pledge, we the students" of the West Bloomfield School District agree to: 1. 2. 3. 4. 5. 6. 7. 8.

Value student differences and treat others with respect. Not become involved in bullying incidents or be a bully. Be aware of the school district's policy and support system with regard to bullying. Report honestly and immediately all incidents of bullying to a faculty member, guidance counselor, or principal. Be alert in places around the school district where there is less supervision such as bathrooms, between buildings, busses, etc. Support students who have been or are subjected to bullying. Participate fully and contribute to homeroom class discussions in dealing with bullying. Provide a good role model for younger students and support them if bullying occurs.

I acknowledge that whether I am being a bully or see someone being bullied, if I don't report or stop attempt to stop the bullying, I am just as guilty.

Signed: ________________________________________________________________ Print Name: ______________________________________ Date: _________________

HEALTH APPRAISAL

Developed in Cooperation With: Departments of Consumer & Industry Services, Community Health, and Education; Michigan State Medical Society;

School Children's Group Child Care Center Child Caring Institution

Michigan Association of Osteopathic Physicians and Surgeons

Other: ______________

Dear Parent or Guardian: The following information is requested so that the school and parent can work together to meet the physical, intellectual, and emotional needs of the child. Fill out the information requested in Section I. Section II may be certified by transcription of information from the certificate of immunization. The remaining sections (111, IV, V) are to be completed by a doctor, nurse, and dentist. (BE SURE TO BRING YOUR CHILD'S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL Child’s Name

Sex Last

First

Date of Birth

Middle

Address

Today’s Date Number & Street

City

Zip

Parent’s or Guardian’s Name

Telephone (Home) Last

First

Middle

Address

Telephone (Work) Number & Street

City

SECTION I -- HEALTH HISTORY Is your child having any of the problems listed below?

Yes

No

1. Allergies or reactions: (for example, food, medication, or other)

Zip

SECTION II --IMMUNIZATIONS Statements such as "UP TO DATE" or "COMPLETE" will not be accepted. Admission to school may be denied on the basis of this information. * VACCINE DATE ADMINISTERED Type

Mo/Day/Yr.

DTaP/DTP/Td (Specify Type)

2. Hay fever, asthma, or wheezing

1.

Type

Mo/Day/Yr. 6.

3. Eczema or frequent skin rashes

2.

7.

4. Convulsions/Seizures

3.

8.

5. Heart trouble

4.

9.

6. Diabetes

5.

10.

7. Frequent colds, sore throats, earaches (4 or more per year)

Haemophilus influenzae type b (HIB)

8. Trouble with passing urine or bowel movements

POLIO IPV/OPV (Specify Type)

9. Shortness of breath 10. Speech problems 11. Menstrual problems

1.

3.

2.

4.

1.

4.

2.

5.

3. Note: If Measles, Rubella, or Mumps vaccines were given before 12 months of age, the dosage must be repeated.

12. Dental problems: date of last examination: 13. Other

MMR Varicella (Chickenpox)

1.

2.

1. 2.

Please explain any problem areas identified above:

Hepatitis B HBV

1.

3.

2. Pneumococcal Conjugate (PCV)

1.

3.

2.

4.

Other Vaccines

Indicate physician diagnosis or laboratory evidence of immunity as applicable VACCINES WAIVED DUE TO REACTIONS/CONTRAINDICATIONS/ RELIGIOUS OBJECTIONS Does your child take any medications regularly?

Yes

No

I certify that the immunization dates are true to the best of my knowledge

If yes, what medication? Reason for Medication: Parent’s Signature: Validating Signature

Title

Date

*According to Act 368, Public Acts of 1978, any child enrolling in a Michigan school for the first time must be adequately immunized, vision tested and hearing tested. Exemptions to these requirements are granted for medical, religious, and other objections provided that waiver forms are properly prepared, signed, and delivered to school administrators. Forms for these exemptions are available at your school or local health department.

SECTION III -- PHYSICAL EXAMINATION, INSPECTION, TESTS, AND MEASUREMENTS EXAMINATIONS AND/OR INSPECTIONS ESSENTIAL FINDINGS DEVIATING FROM NORMAL AND/OR RECOMMENDATIONS

TESTS AND MEASUREMENTS Normal Vision Tested? Yes

Under Care

Referred

Normal

Visual Activity

No

Yes

No

Albumin

Date_______________

Other_______

Date______________

Hearing Tested?

Audiometer

Blood Pressure Measured?

Yes

No

Other_________

Yes

Microscopic

No

Date____________________

Reading__________________

Hemoglobin/Hemotocrit Tested?

Height_____________

Yes

No

Yes

Weight_________

Other: Blood Lead level recommended for all children age six and under

Blood Lead Level Tested? No

Date______________

Referred

Sugar

Urinalysis Done?

Ocular Muscle

Under Care

Reading__________

ESSENTIAL FINDINGS DEVIATING FROM NORMAL AND/OR RECOMMENDATIONS

Tuberculin Test (if given)

Date _______________

Type____________

Negative

Positive ___________________ mm.

SECTION IV -- RECOMMENDATIONS Is there any defect of vision, hearing, or other condition for which the school could help by seating or other action?

Yes

No

If yes, please explain:

Should the student’s activity be restricted because of any physical defect or illness? Classroom

Playground

Examiner’s Signature

Gymnasium

Yes

Date

Number & Street

No

Swimming Pool

If yes, check below and explain degree of restriction: Competitive Sports

Camp

Other

Examiner’s Name (print or type)

City

Degree or License

Zip

Telephone

SECTION V -- DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL) I have examined

teeth and make the following recommendations as for treatment: Child’s Name

Dentist’s Signature

COMMENTS

MDCH.BRS-Revised 3-2001

Date

Educational Material for Parents and Students (Content Meets MDCH Requirements) Sources: Michigan Department of Community Health. CDC and the National Operating Committee on Standards for Athletic Equipment (NOCSAE)

UNDERSTANDING CONCUSSION Some Common Symptoms Headache Pressure in the Head Nausea/Vomiting Dizziness

Balance Problems Double Vision Blurry Vision Sensitive to Light

Sensitive to Noise Sluggishness Haziness Fogginess Grogginess

Poor Concentration Memory Problems Confusion “Feeling Down”

Not “Feeling Right” Feeling Irritable Slow Reaction Time Sleep Problems

WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a fall, bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. A concussion can be caused by a shaking, spinning or a sudden stopping and starting of the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious. A concussion can happen even if you haven’t been knocked out. You can’t see a concussion. Signs and symptoms of concussions can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If the student reports any symptoms of a concussion, or if you notice symptoms yourself, seek medical attention right away. A student who may have had a concussion should not return to play on the day of the injury and until a health care professional says they are okay to return to play.

IF YOU SUSPECT A CONCUSSION: 1. SEEK MEDICAL ATTENTION RIGHT AWAY – A health care professional will be able to decide how serious the concussion is and when it is safe for the student to return to regular activities, including sports. Don’t hide it, report it. Ignoring symptoms and trying to “tough it out” often makes it worse. 2. KEEP YOUR STUDENT OUT OF PLAY – Concussions take time to heal. Don’t let the student return to play the day of injury and until a heath care professional says it’s okay. A student who returns to play too soon, while the brain is still healing, risks a greater chance of having a second concussion. Young children and teens are more likely to get a concussion and take longer to recover than adults. Repeat or second concussions increase the time it takes to recover and can be very serious. They can cause permanent brain damage, affecting the student for a lifetime. They can be fatal. It is better to miss one game than the whole season. 3. TELL THE SCHOOL ABOUT ANY PREVIOUS CONCUSSION – Schools should know if a student had a previous concussion. A student’s school may not know about a concussion received in another sport or activity unless you notify them.

SIGNS OBSERVED BY PARENTS: • • •

Appears dazed or stunned Is confused about assignment or position Forgets an instruction

• Can’t recall events prior to or after a hit or fall • Is unsure of game, score, or opponent • Moves clumsily

• • •

Answers questions slowly Loses consciousness (even briefly) Shows mood, behavior, or personality changes

CONCUSSION DANGER SIGNS: In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. A student should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs: • • • •

One pupil larger than the other Is drowsy or cannot be awakened A headache that gets worse Weakness, numbness, or decreased coordination

• • • •

Repeated vomiting or nausea Slurred speech Convulsions or seizures Cannot recognize people/places

• Becomes increasingly confused, restless or agitated • Has unusual behavior • Loses consciousness (even a brief loss of consciousness should be taken seriously.)

HOW TO RESPOND TO A REPORT OF A CONCUSSION: If a student reports one or more symptoms of a concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of athletic play the day of the injury. The student should only return to play with permission from a health care professional experienced in evaluating for concussion. During recovery, rest is key. Exercising or activities that involve a lot of concentration (such as studying, working on the computer, or playing video games) may cause concussion symptoms to reappear or get worse. Students who return to school after a concussion may need to spend fewer hours at school, take rests breaks, be given extra help and time, spend less time reading, writing or on a computer. After a concussion, returning to sports and school is a gradual process that should be monitored by a health care professional. Remember: Concussion affects people differently. While most students with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer. To learn more, go to www.cdc.gov/concussion.

Parents and Students Must Sign and Return the Educational Material Acknowledgement Form

CONCUSSION AWARENESS EDUCATIONAL MATERIAL ACKNOWLEDGEMENT FORM By my name and signature below, I acknowledge in accordance with Public Acts 342 and 343 of 2012 that I have received and reviewed the Concussion Fact Sheet for Parents and/or the Concussion Fact Sheet for Students provided by ________________________________________________________ Sponsoring Organization ___________________________________ Participant Name Printed

___________________________________ Parent or Guardian Name Printed

___________________________________ Participant Name Signature

___________________________________ Parent or Guardian Signature

___________________________________ Date

___________________________________ Date

Return this signed form to the sponsoring organization that must keep on file for the duration of participation or age 18. Participants and parents please review and keep the educational materials available for future reference.

Friday September 5, 2014 Dear Parents, Thank you for your support during our transition to a 1:1 mobile device learning environment. We are ready to implement the next phase of this transition so your child has full access to the educational tools and resources provided in the Google Apps for Education suite. Your child will access these

tools using their secure, filtered West Bloomfield School Distdct Iogin. Prior to setting up account access and distributing Iogin information, we need your permission. By

reviewing the informational letter below and signing this form, you will be giving West Bloomfield School Distdct permission to create a Google Account for your child. After we receive your permission, your child will receive a unique usemame and password under the wbsd.org domain. This form needs to be completed for each student by September 10, 2014. You will have the option

to submit another form if you have multiple children in the West Bloomfield School Distdct. This usemame and password will allow your child to: Share files (Google Apps) with teachers ÿ) and other students (studeÿ!ÿ9) Access Google Ddve (docs, slides, sheets, forms, drawings, classroom)

Access Gmail, calendar, contacts (within the WBSD domain only) Access the intemet through the West Bloomfield School Distdct and Oakland Schools filtered networks If you have any questions, please do not hesitate to contact me. We look forward to this exciting, educational endeavor. Sincerely, Morrison Borders,

Orchard Lake Middle School Pdncipal * Required

Student Information Student First Name *

Student Middle Name *

Student Last Name *

Grade Level *

i "i Google Apps for Education Account Information and Parental Permission Google Account Information * PARENTS: Please read the Google Apps for Education Account hlformation letter found at • Initial below to indicate that you have read the Google Apps for Education Account Information letter and you are givirlg permission for the West Bloomfield School District to give your child access to a Google Account under the wbsd.org domain,

Parent Full Name *

Parent Email *

submit

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The West Bloomfield School District is committed to enhancing instruction through the use of technology. Our goal is to create an environment where students use technology to access a vast amount of resources, tools, and instructional delivery methods to differentiate, support, and enhance their learning. The use of a laptop computer, Chromebook, or tablet with a keyboard is recommended for all classes at Orchard Lake Middle School. These devices will be an important part of the instructional delivery model. We would love to have as many students as possible commit to bringing their own device, but do have an option for students to use a distdct-provided device. To support our planning, this form needs to be completed for each student by August 20, 2014. If you have multiple children in our school, you will have the option to submit another form upon completion.

You and your child will also be asked to review and indicate an understanding of technology policies related to the use of mobile computing devices and the West Bloomfield School Distdct WiFi network. Please take the time to go through each policy with your child/children. These policies are designed to support a robust, 1:1 learning environment while also ensuring the safety and protection of our students. Thank you in advance for your time. Morrison Borders

Principal * Required

Student Last Name ÿ

Student First Name ÿ

Student Middle Name ÿ

Grade student will be in during the 2014-2015 school year, *

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Oÿ ÿnaÿd Lalÿe ÿiÿidcl]e ocr]oo] Device Commlbÿent Form ÿmd Requested Technology Polÿcÿ,ÿ:,ÿ * Required

Device Options and Selection Please read the device options. Indicate your choice below.

Option 1: BRING YOUR OWN DEVICE: By selecting this option you are indicating that you wilt NOT checkout a district-owned Chromebook, and are instead selecting for your son/daughter to use a personal

device. The device can be a laptop, tablet, or Chromebook that has WiFi capability, an updated operating system (with word processing, presentation, spreadsheet software) anti-virus software, and 6 hours or mere of battery life. You may want to visit the Sehi Computer Products portal for

educational pricing (on a limited number of devices) at hthÿp:l/vwwv.buysehi.cemlsystem dept.asp? dept id=SD-005. This special pricing has been extended through September 1, 2014. Option 2:

PURCHASE THE SAME MODEL OF CHROMEBOOK WBSD IS USING: If you would like to purchase the same model Chromebook that WBSD is using, you may use our preferred vendor, Sehi

Computer Products, and receive educational pricing. This special pdcing has been extended through September 1, 2014. WBSD will be using the 2214874 - Samsung 11" Chromebook Sedes 3. You can access the WBSD Sehi Computer Product's portal at http://www.buvsehi.com/svstem dept.asp?

deptid=SD-005 Option 3: CHECK OUT A DISTRICT-OWNED and MANAGED CHROMEBOOK: By selecting this option you are indicating that you are going to use a Distdct-Owned Chromebook and return it at the end of the school year. You and your student must read the Caring For a District-Provided Device policy found at http://qoo.ql/MVLOVk. You must initial below to indicate understanding and agreement of the policy. This MUST be signed prior to your student receiving a Chromeboek. Choose the option that you will be selecting for your child, *

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ONLY COMPLETE THIS PORTION IF YOUR CHILD WILL BE USING A DISTRICT=PROVIDED DEVICE PARENTS: Please read the Caring For A District-Provided Device policy found at http:llqoo.qllMVLOVk and initial below that you understand and agree•

STUDENTS: Please read the Caring For A District-Provided Device policy found at http://aoo.ul/MVLOVk and initial below that you understand and agree.

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* Required

Technology Policies For All Students and Parents to Review PARENTS: * Please read the Acceptable Use Policy (AUP) found at Lÿttÿ:i/gÿgl/a3RVUV and initial below that you understand and agree.

PARENTS: * Please read the Using Personal and District-Provided Mobile Devices At School policy found at httÿW7K and initial below that you understand and agree.

STUDENTS: * Please read the Acceptahle Use Policy (AUP) found at tÿoo.ÿl/a3RVUV and initial below that you understand and agree.

STUDENTS: * Please read the Using Personat and District-Provided Mobile Devices At School policy found at and initial below that you understand and agree.

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RETURN THIS FORM ONLY IF YOU 5810 Commerce Road West Bloomfield, MI 48324 248-865-6420 www.wbsd.org

DO NOT WANT YOUR CHILD PHOTOGRAPHED

DO NOT PHOTOGRAPH FORM 

Permission is DENIED, to use my child’s image or voice in any videos or photographs taken of the activities in his/her classroom, elsewhere in the school, or on school grounds, for internal use within the school, classroom, or district.



Permission is DENIED, to include my child’s image or voice in any videos or photographs taken of the activities in his/her classroom, elsewhere in the school, or on the school grounds, in external PUBLICATIONS, BROADCASTING or on the INTERNET for educational, informational or publicity purposes.



I understand that by signing this form and returning it to my child’s school, my child will be designated DO NOT PUBLISH until I provide the school with written permission to include him/her again.

Student Name (print) ______________________________________________________ Parent Name (print) ______________________________________________________ Parent Signature _________________________________________________________ School_____________________________________Date_______________________

If student is 18 yrs. or older, student must also sign this form. Student Name (print) ______________________________________________________ Student Signature_________________________________________________________ Date ___________________________________________________________________

West Bloomfield School District Community Relations 248.865.6454 • FAX 248.865.6451