2019/2020 Family Handbook Signature Page (Please complete a separate form for each student)

We have read the CSA and/or CSPA Family Handbook. Our signature below indicates our understanding of the procedures and policies contained therein and our intent to abide by them.

Student Name Signature of Student Date

Parent/Guardian Name Signature of Parent/Guardian Date

revised August 2019

NETWORK AND INTERNET ACCEPTABLE USE AGREEMENT The Academy is committed to the effective use of technology to both enhance the quality of student learning and the efficiency of Academy operations. It also recognizes that safeguards have to be established to ensure that the Academy’s investment in both hardware and software is achieving the benefits of technology and inhibiting negative side effects.

In order for anyone to use the local and wireless network, Internet connection and/or data and exchange servers, he/she must read these guidelines and sign this Agreement.

A user name and password will be issued to users upon receipt of this signed Agreement. Until then network use will not be allowed. The use of the Internet is a privilege, not a right. Inappropriate behavior or violation of the acceptable use agreement may lead to penalties including the revocation of a user’s account, disciplinary action, including suspension and/or expulsion, and/or legal action.

Inappropriate Internet and network use is not limited to the following: • using offensive or inappropriate language or language that would promote violence or hatred; • revealing one’s (or other’s) personal address, phone number or credit card information; • harassing anyone by sending uninvited communication; • sending or accessing electronic information from accounts that do not belong to you without the owner’s authorization; • accessing unauthorized or inappropriate areas of the network and changing or interfering with information found in the network; • accessing areas blocked by the Academy’s firewall without authorization; • soliciting or distributing e-mail for non-educational or non-business purposes; • misrepresenting oneself or others; • making unauthorized copies of software or information, such as software pirating; • printing of materials excessively; • downloading and/or installing unauthorized software, including games, on Academy computers; • accessing, uploading, downloading, distributing, or transmitting pornographic, obscene, sexually explicit, or threatening material or other materials harmful to minors; • violating federal copyright laws or otherwise using the property of another individual or organization without permission. All work must be original work. Copy and pasted material may only be used as a resource when properly cited; • violating any local, state or federal statute; and • accessing personal social networking sites, such as but not limited to Facebook, Twitter, MySpace, YouTube, Instagram, Snap Chat, Tumblr, Pinterest, Vine, Yik Yak, VK, Google+, Linkedin, Flickr etc. without specific permission from the Administration.

I agree to comply with these Network and Internet Acceptable use guidelines as stated in this Agreement and the Academy Student/Family Handbook.

I understand that the Academy administration reserves the right to change these rules at any time.

Rev. August 2019

I understand that the assignment of a password does not guarantee confidentiality. There is no expectation of privacy as to prevent examination or monitoring. I understand that the Academy reserves the right to examine all data stored in the machines and/or network (including e-mail) to make sure that all users are in compliance with these regulations. The Academy reserves the right to monitor or review Internet files, including web pages and usage logs. Any flash drive used at the Academy must also be free of any inappropriate content.

I agree not to participate in the transfer of inappropriate or illegal materials or material that may be considered treasonous or subversive through the Network and Internet connection. I realize that in some cases, the transfer of such material may result in legal action against me.

I understand that the Academy monitors the on-line activity of all users in an effort to restrict access to child pornography and other material that is obscene, objectionable, inappropriate and/or harmful to minors in accordance with the Children’s Internet Protection Act (CIPA).

Should I happen to find materials that may be deemed inappropriate, I shall refrain from downloading this material, immediately leave the Internet site, shall not identify or share the location of this material, and will immediately report it to a teacher or the Administration. I am aware that the transfer of certain kinds of materials is illegal, and punishable by fine or jail sentence.

I understand that all computers, local and wireless network, Internet connection and/or data and exchange servers are the Academy’s property and shall only be used for educational and business purposes.

I understand that computer hardware (monitors, terminals, keyboards, mice, etc.) are Academy property and any mistreatment or damage will be considered destruction of property or vandalism.

I understand that the Academy makes no guarantees, implied or otherwise, regarding the reliability of the data connection. The Academy and any of the sponsoring organizations shall not be liable for any loss or corruption of data resulting while using the Internet connection.

I understand that the Academy strongly condemns the illegal distribution of software otherwise known as pirating. I understand that software piracy is a Federal offense punishable by fine or imprisonment.

I agree not to allow other individuals to use my account or use other individuals’ accounts for Network and Internet activities.

I understand that through the use of the Internet any actions taken by me will reflect upon the Academy system as a whole. As such, I shall behave in an ethical and legal manner. ------********************CSPA STUDENTS ONLY: CHECK APPLICABLE BOX BELOW*************************** My student would like to bring a personal electronic device to school. My student will only be accessing Academy-owned electronic devices while at school. ------Signature of Student ______Date ______

A parent or legal guardian must also sign the following section:

I, ______(print name), the parent/guardian of ______(print student’s name), agree to accept all financial and legal liabilities that may result from my son’s/daughter’s use of the Academy’s Network and Internet connection. I release and agree to hold the Academy, and all other sponsoring organizations related to the Internet connection, from any and all liability foreseeable or unforeseeable for damages or injury resulting directly or indirectly from the use of the Internet connection. I also agree to defend, indemnify, and hold harmless the Academy, its Board members, staff and agents from and against any such claims, demands, suits, damages, liability, costs, and expenses (including reasonable attorney fees) incurred as a consequence either directly or indirectly of the granting of this agreement.

Signature of Parent/Guardian ______Date ______

------This policy and all its provisions are subordinate to local, state, and federal statutes.

Rev. August 2019

9758 Highland Road Howell, Michigan 48843-9008 Office # 810-632-2200 Fax # 810-632-2201

Consent for child to participate in physical education in the CSA District

I understand that my child will be participating in a physical education program at Charyl Stockwell Academy.

□ My child has no known medical / physical limitations that would prevent him / her from participating.

□ My child has the following limitations:

Child’s Name:

Parent’s Name:

Parent’s Signature:

Date

PARENT & ATHLETE CONCUSSION INFORMATION SHEET

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 bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION? SYMPTOMS REPORTED BY ATHLETE: Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or • Headache or “pressure” in head weeks after the injury. • Nausea or vomiting • Balance problems or dizziness If an athlete reports one or more symptoms of concussion • Double or blurry vision after a bump, blow, or jolt to the head or body, s/he should • Sensitivity to light be kept out of play the day of the injury. The athlete should • Sensitivity to noise only return to play with permission from a health care • Feeling sluggish, hazy, foggy, or groggy professional experienced in evaluating for concussion. • Concentration or memory problems • Confusion • Just not “feeling right” or is “feeling down”

DID YOU KNOW? SIGNS OBSERVED • Most concussions occur without loss of consciousness. BY COACHING STAFF: • Athletes who have, at any point in their lives, had a concussion have an increased risk for • Appears dazed or stunned another concussion. • Is confused about assignment or position • Young children and teens are more likely to • Forgets an instruction get a concussion and take longer to recover • Is unsure of game, score, or opponent than adults. • Moves clumsily • Answers questions slowly • Loses consciousness (even briefly) • Shows mood, behavior, or personality changes • Can’t recall events prior to hit or fall • Can’t recall events after hit or fall

“IT’S BETTER TO MISS ONE GAME

THAN THE WHOLE SEASON” Rick Snyder, Governor James K. Haveman, Director CONCUSSION DANGER SIGNS WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS? In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain If an athlete has a concussion, his/her brain needs time to against the skull. An athlete should receive immediate heal. While an athlete’s brain is still healing, s/he is much medical attention if after a bump, blow, or jolt to the more likely to have another concussion. Repeat concussions head or body s/he exhibits any of the following danger can increase the time it takes to recover. In rare cases, signs: repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even • One pupil larger than the other be fatal. • 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 or places • Becomes increasingly confused, restless, or agitated STUDENT-ATHLETE NAME PRINTED • Has unusual behavior • Loses consciousness (even a brief loss of consciousness should be taken seriously)

STUDENT-ATHLETE NAME SIGNED

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION? DATE 1. If you suspect that an athlete has a concussion,

remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play. PARENT OR GUARDIAN NAME PRINTED

2. Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on PARENT OR GUARDIAN NAME SIGNED the computer, and playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional. DATE

3. Remember: Concussions affect people differently. While most athletes 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.

JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp

TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION

Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

1032 Karl Greimel Dr. 9758 E Highland Rd. Brighton, MI 48116 Howell, MI 48843 School Year 810-225-9940 phone 810-632-2200 phone 810-225-9941 fax 810-632-2201 fax Parent/Guardian Permission for OVER-THE-COUNTER (OTC) Medication Only one medication per form

Name

Classroom Age_

Date of Birth Weight (if required for dose)

Medication name Exact Dose

Condition for use (such as headache)

_YES NO Medicine to be taken with food?

Other directions

YES NO Parent/Guardian to be notified with every use of this medication

For High School or Middle School students only: (please check option 1 or 2 below)

1. Student can self-administer medication(s) in the presence of an authorized staff member EXCEPT AT MIDDLE SCHOOL CAMP.

2. Student can keep the medication(s) in his/her possession and self-administer as needed EXCEPT AT MIDDLE SCHOOL CAMP.

Other times to call or special instructions-

OTC medication without a doctor’s written permission will have limited use at school – SEE PAGE 2 F0R RULES

Parental Permission

It is my understanding that the Academy has taken every precaution to safeguard my child. I release and agree to hold the Academy, its Board members, staff working at the Academy, volunteers, and agents harmless from any and all liability foreseeable or unforeseeable for damages or injury resulting directly or indirectly from the administration of the medication/treatment.

I also agree to defend, indemnify, and hold harmless the Academy, its Board members, staff working at the Academy, volunteers and agents from and against any such claims, demands, suits, damages, liability, costs, and expenses (including reasonable attorney fees) incurred as a consequence either directly or indirectly of the granting of this authorization to administer the medication/treatment.

I have read the guidelines on page three of this form for the administration of over-the-counter medication at school. I give my permission for the above named medication (supplied by me) to be given by school staff as directed on this form.

Parent/Guardian Date Signature

Phone Number Alternative number

revised November 2017 Guidelines for parents and school staff regarding over-the-counter (OTC) medication at school without an order from a physician/licensed prescriber:

•All medication must be in the original container and an unopened container is recommended. •Write the exact dose (amount of medication to be given, not a range) on page 1 of this form. •Write your child’s name on the medicine bottle or packaging without covering the label. •Only one medication per form. You will need a separate form for every over-the-counter medication. •Write the exact name of the medication to be given on page 1 of this form. •Write the condition for use (such as, headache or menstrual cramps.) •Aspirin will not be given to students without a doctor’s order on a “Prescription Medication” form due to its association with Rye’s Syndrome. •Stomach pain will not be treated with acetaminophen, ibuprofen or naproxen without a medical order on the “Prescription Medication” form due to lack of indication. Menstrual cramps are not considered stomach pain. •No over-the-counter medication will be given frequently or for a prolonged period of time. If your child is experiencing the need for frequent or regular administration of this medication at school, you will be notified. To continue giving this over-the-counter medication, a physician or licensed prescriber’s order will be required. This is to help insure that a serious condition is not being ignored or a more appropriate treatment is not being overlooked. •If your child is sick it is not appropriate to treat the symptoms at school. Medication may help symptoms briefly or reduce a fever, but he or she is still contagious and should go home. •Cough drops have the potential to be a choking hazard and should only be used for short period of time. If your child’s cough persists, a medical professional should be consulted. •Over-the-counter Benadryl or other antihistamines ordered for a potentially life threatening allergy (anaphylaxis) must be ordered as part of the Severe Allergy Medical Action Plan (MAP) and signed by the physician. •Over-the-counter Benadryl or other antihistamines for mild food allergies must be ordered by a licensed prescriber and can be done on the “Prescription Medication” form without completing a Medical Action Plan for severe allergy. Parent/guardians may order over-the-counter antihistamines only for mild allergies that are not caused by food, such as hay fever. •For the purpose of this form, over-the-counter medication includes vitamins and homeopathic remedies.

NOTE: •The very first dose of this medication type may not be given at school since it is not known how your child may react to the medicine. •Unused medication may be picked up by a parent/guardian anytime before the end of the school year. Medication remaining after the last day of school will be properly discarded.

Parents/guardians have the right to come to school and give medication to their child without an order form on file. However, all sick children should be home to help protect others.

If you have questions regarding the guidelines above, please feel free to contact the school.

Parent/Guardian Signature Date

revised November 2017

EMERGENCY / MEDICAL INFORMATION

Last Name Student M.I. First Name Birth Date

Gender Male Female Primary Ethnicity Secondary Ethnicity

Street Address City State Zip

Parent/Guardian#1 Last Name First Name

Street Address City State Zip

Home Telephone# Cell# Work #

Parent/Guardian#2 Last Name First Name

Street Address City State Zip

Home Telephone# Cell# Work #

Aller gies/M ed ical Con d it ion s (please ch eck all th at ap p ly and give d et ails in t h e “E xp lan at ion s” are a).

1 No known problems 2 Medical Waiver 3 Arthritis 4 Cardiac

5 Hemophelia 6 Diabetes 7 Aspirin Allergy 8 Penicillin Allergy

9 Iodine Allergy 10 Multiple Allergies 11 Epilepsy 12 Contact Lenses

13 Blood Condition 14 Sulfa Allergy 15 Frequent Nosebleeds 16 Asthma (is inhaler required)

17 Hearing Impaired 18 Animal Allergy 19 Codeine Allergy 20 Environmental Allergy

21 Food Allergy (list below) 22 Insect Allergy 23 Daily Medications 24 Special Needs (list below)

25 Medical Alert 26 Other 27 Other 28 Other

Explanations from above ( Please Reference the Condition Number)

In the event we need to reach you and are unable to do so, please list two local persons that we may contact and release your child to.

Last Name First Name Home# Cell#

Last Name First Name Home# Cell#

In addition to the parent(s)/guardians(s) and alternative contacts, the child named above may be released to the following people upon verification of ID.

Last Name First Name Home# Cell#

Last Name First Name Home# Cell#

Please list the name(s) of any person who should be EXCLUDED from picking up the child named on this form

Last Name First Name Home# Cell#

Parent/Guardian Signature Date

Volunteer Form 2019 / 2020 (Must be completed each year.)

Volunteer Information: Last Name First Name Middle Initial

Street Address City Zip Code

Email Address

Home Phone Cell Phone

Date of Birth Race Male / Female

Parent / Guardian / Other: Student’s Name

MI Driver’s License Number Date of Expiration

Any other last names used: Any other first names used:

Will your volunteer service include driving Academy students? yes no

Vehicle Information: Name of Owner

Owner’s Street Address City Zip Code

Year/Make Model License Plate #

Insurance Information: Insurance Company

Policy # Expiration Date

Please check one: 1. I have not been convicted of, or pled guilty or nolo contendere (no contest) to any crimes.

2. I have been convicted of or pled guilty or nolo contendere (no contest) to the following crimes (use separate sheet to explain nature of conviction, date and court):

a.

b.

Certification of Policy & Authorization: I understand and agree that the Academy will be requesting a criminal history background check on my behalf from the Internet Criminal History Access Tool (ICHAT). As a chaperone, I will not purchase any items for any students during field trips. I understand that as a volunteer driver, I must be 21 years of age or older, hold a valid driver’s license, have enough working seat belts for each child I transport, and have the required coverage in effect on any vehicle used to transport the children during the current school year. I may only transport the children from the Academy to the destination and back and will not be making any other stops.

Copy of driver’s license is required.

Signature: Date:_

Student Residency Questionnaire

This questionnaire is intended to address the McKinney-Vento Act, in regards to children and youth in transitional living arrangements. Your answer will help the administration determine residency documents necessary for enrollment and additional services available to your family. This questionnaire will be kept separately from the student’s permanent record and filed by the Homeless Education Liaison.

School:_

Name of Parent/Guardian:_

Address:_

Phone:_

Student Names:_

Signature of Parent/Guardian: Date

1. Presently, where is the student living? Please check one:

in a shelter with more than one family in a house or apartment in a motel, car or campsite with friends or family members (other than parent/guardian) awaiting foster care placement none of the above. If you checked this item, skip number 2 and go directly to number 3.

2. The student lives with:

1 parent 2 parents 1 parent & another adult a relative, friend(s) or other adult(s) alone with no adults an adult that is not the parent or the legal guardian

3. Mark one of the following:

Parent(s)/Guardian(s) is NOT an active member of the military Parent(s)/Guardian(s) is an active member of the military Parent(s)/Guardian(s) was in the military but no longer active (Veteran)

Revised 8-9-2017

Information Opt Out Form

(THIS FORM IS OPTIONAL - If you do not wish to opt-out of any information you do not need to complete this form or take any other action)

Academy name:

Student name:

Student grade:

Parent or guardian name:

I understand that the Family Educational Rights and Privacy Act (FERPA), a federal law, allows the Academy to disclose designated “directory information” to third parties without my written consent, unless I inform the Academy otherwise. “Directory information” is information that is generally not considered harmful or an invasion of privacy if released.

The Academy may not share my child’s directory information for the following purposes as checked below:

o Academy publications, including but not limited to, a yearbook, graduation program, honor roll or other recognition lists, theater playbill, athletic team or band roster, newsletter, and other Academy publications o U.S. Military recruiters o Colleges and other educational institutions o Prospective employers o National Student Clearinghouse o News media outside the Academy o Academy PTA or parent organization o Other groups and entities outside of the Academy, including community, advocacy and/or parent organizations o Official Academy-related websites or social media accounts

The Academy may not share any of the following checked directory information for the purposes indicated above:

o Student name o Student address o Telephone numbers (e.g., home, cell, etc.) o Academy assigned email address o Date and place of birth o Participation in officially recognized activities or sports o Weight and height of members of athletic teams o Photograph, DVD, video or electronic image o Honor roll, awards received o Dates of attendance o Grade level and/or classroom assignment o All of the above

Parent/Guardian signature (if student is under 18):

Student signature (if student is over 18):

Date:

revised August 2017