Parent/Guardian Consent Form

Please note that you must complete this form for each of your students enrolled with GRPS

Student's ID Number: *

Student's First Name: *

Student's Last Name: *

Student's Date of Birth: * +

What school will your student be attending for the 2020-2021 school year? *

I consent that my student may: *

	Yes	No
Be photographed/videoed/interviewed for school-related material	Yes	No
Be photographed/videoed/interviewed for District-related material	Yes	No
Be photographed/videoed/interviewed for non-GRPS media (ex: publications of our partners or agencies we work with)	Yes	No
Be sent emails	Yes	No
Be transported to home or to a caregiver	Yes	No
Be transported to a health evaluation or screening	Yes	No
Utilize the internet	Yes	No

As the parent/guardian, I consent that I may: *

Armed Services

	Yes	No	N/A
My student's information may be released to Military Recruiters	Yes	No	N/A

I consent that my student may: *

	Yes	No
Receive health and human services provided by Kent School Services Network: KSSN brings health and human services into the building to support student achievement by serving students and families.In addition to KSSN staff, staff from the following KSSN partner agencies may work with your child: Arbor Circle, DA Blodgett/St. John's, Kent County Dept. of Health and Human Services, Cherry Health	Yes	No
Receive free vision screening provided by Vision to Learn: VTL provides free vision screening	Yes	No
Receive eye exam(s) and eyeglasses provided by Vision to Learn. This may be billed to my Medicaid benefits	Yes	No
Receive free hearing screenings provided by the Kent County Health Department	Yes	No
Receive free vision screenings provided by the Kent County Health Department	Yes	No
Provide immunization records to Kent County Health Department	Yes	No
Receive free dental services provided by Cherry Health Dental Services. This may include dental exams, x-rays, cleaning, fluoride and sealants at school, at no charge to you. However, if your child has dental insurance or Medicaid these carriers will be billed as payment in full. If your child plans to be seen by a non-Cherry Health dental office in the next year your insurance may not cover duplicated services	Yes	No
Receive medical services provided by Cherry Health School-based Health Centers	Yes	No
Receive counseling services provided by Cherry Health School-based Health Centers	Yes	No

As a Parent/Guardian of the above student: *

	Yes	No
I understand that the District plans to share information with program evaluators from Grand Valley State University's Community Research Institute (CRI) for use in an evaluation of out of school time programs	Yes	No
I understand that my student will be utilizing technology and devices and must adhere to the District's Acceptable Use policy contained in the Student Policy Handbook. I agree to indemnify the District of any monetary liability incurred by the student while utilizing the District's technology or the Districts network	Yes	No

As the Parent/Guardian of the above student, I understand and consent to: *

	Yes	No
My student may participate in a number of chaperoned field trips that may include but are not limited to: various attractions, college campuses, professional environments/buildings, other GRPS schools, and other special events	Yes	No
My student may be transported to and from school for field trips, and school related activities, in automobiles that may be owned by the school, or by an employee or volunteer. I understand that these vehicles are not school buses, and as such, are not in compliance with all current regulations for school buses. I feel that the additional risk of transporting my child in a car, as opposed to a bus, is acceptable as it allows my child educational enrichment beyond the classroom environment	Yes	No

As the parent/guardian of the above student, I have read and understand all of the prompts to which I have provided answers. *

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