✁

EMERGENCY CONTACT 1 Relationship to student: __________________

Name: ___________________________ Occupation: ____________________________________

Phone: _________________________ Mobile phone: ______________________ Work phone: ______________________

CUSTODY ISSUES Note custody issues here. Attach copy of Court Order, etc

MEDICAL INFORMATION: To help us care for your child in any illness or emergency situation, would you please answer the following questions. This information will be strictly confidential (Privacy Act 1993) and will only be revealed to necessary staff members to ensure the safety of your child. If you wish to discuss any health concerns further, contact the School First Aider on 4446582 ext 802.

1. Medication: I give permission for Panadol to be administered if required. � Yes � No

2. Existing Medical Conditions (eg Asthma, Diabetes, Epilepsy, Rheumatic Fever, Hepatitis A, B, or C, HIV, Glandular Fever, Migraines, Heart Conditions, ADHS, Nose Bleeds, Skin condition) _______________________________________________

____________________________________________________________________________________________________

3. Asthma Sufferers Only: Reliever:______________________________ Preventer:______________________________

Has your child been hospitalised with Asthma?___________ Does your child have an Asthma Plan?___________________

If “yes”, please give a copy of the Plan to the school office.

4. Allergies:____________________________________________________ Treatment______________________________

Does your child have an Anaphylaxis Plan?____________ If “yes”, please give a copy of the Plan to the school office 5.

Family Doctor: _____________________________________________ Phone No:________________________________ PARENT/CAREGIVER UNDERTAKING

q

I acknowledge that all the information provided is true and correct. I accept that in signing this form, we abide by the policies, rules and regulations of the school

q

I will support the school to ensure that my child will (a) be punctual; (b) wear correct uniform (clearly named); (c) obey school rules q

W

here my child damages school property I will make some form of restitution q

I agree to pay the technology/specialist levies

q

I give permission for the personal and educational data collected relating to my child to be stored and used as defined in the Privacy Act 1993 and disclosed to the next school my child attends

q

I will advise the school office of any change of address or contact telephone numbers q

I will also advise the school office in the event of any custody changes that may affect access to my child

q

If a child requires special medication at school, a Medical Consent form must be filled out. Medication must be labelled clearly and instructions explicit. Medication will be kept in the Health and W

ell-being Room. Signature : _____________________________________________________ Date: _____________________________ CHECKLIST - I have included the following in my enrolment application:

q

Photocopy of Birth Certificate or Passport (with VISAS if not born in NZ) q

Proof of address for In Zone students (power bill, rates bill etc)

q

Photocopy of Year 6 Mid Year Report from primary school (if available) q

Student Digital Technology and Internet use Agreement

q

Online Publication of Student Images q

Blanket Consent for EOTC Form

q

Sporting Intentions Form

Gle

nfie

ld In

term

edia

te S

choo

l

Stud

ent D

igita

l Tec

hnol

ogy

and

Inte

rnet

Use

Agr

eem

ent

Term

s an

d C

ondi

tions

1.

I und

erst

and

that

: i.

the

only

pur

pose

for D

igita

l Tec

hnol

ogy

reso

urce

s is

to s

uppo

rt te

achi

ng a

nd c

lass

room

lear

ning

ii.

th

e sc

hool

will

do

its b

est t

o ke

ep m

e sa

fe w

hile

I us

e gl

obal

info

rmat

ion

syst

ems

such

as

the

com

pute

r an

d th

e In

tern

et. (

Gle

nfie

ld In

term

edia

te S

choo

l cur

rent

ly u

ses

N4L

, as

a fo

rm o

f pro

tect

ion.

Thi

s st

ops

user

s ac

cess

ing

a w

ide

rang

e of

uns

avou

ry s

ites.

iii

. I

know

th

at

I am

no

t pe

rmitt

ed

to

acce

ss

mat

eria

l th

roug

h th

e In

tern

et

that

is

of

fens

ive

(eg.

po

rnog

raph

ic),

dang

erou

s, in

appr

opria

te a

t sch

ool,

or il

lega

l. I

am fo

rbid

den

to p

ass

on s

uch

mat

eria

l by

cop

ying

, sto

ring

or p

rintin

g it

iv.

If I

use

e-m

ail

at s

choo

l, I

am n

ot p

erm

itted

to

send

any

mes

sage

s th

at a

re o

ffens

ive,

dan

gero

us,

inap

prop

riate

at s

choo

l, or

ille

gal

v.

I may

use

the

Inte

rnet

or e

-mai

l at s

choo

l onl

y if

ther

e is

a te

ache

r sup

ervi

sing

me

vi.

I am

not

per

mitt

ed t

o do

wnl

oad

any

softw

are

on s

choo

l com

pute

rs.

Thi

s in

clud

es m

usic

, m

ovie

and

ga

me

files

. vi

i. I m

ay b

e ch

arge

d fo

r exc

essi

ve a

nd u

naut

horis

ed u

se o

f IC

T re

sour

ces,

incl

udin

g In

tern

et ti

me.

2.

I agr

ee to

: i.

take

car

e of

Dig

ital t

echn

olog

y re

sour

ces

ii.

be c

aref

ul w

ith e

quip

men

t and

furn

iture

iii

. re

spec

t the

cop

yrig

hts

on s

oftw

are

that

pro

hibi

t cop

ying

iv

. us

e on

ly s

choo

l sof

twar

e on

sch

ool c

ompu

ters

v.

be

con

side

rate

of o

ther

use

rs

vi.

shar

e av

aila

ble

equi

pmen

t vi

i. be

car

eful

not

to w

aste

com

pute

r res

ourc

es s

uch

as p

aper

, etc

vi

ii. a

void

dis

rupt

ion

of th

e ru

nnin

g of

any

com

pute

r or n

etw

ork

ix.

take

car

e no

t to

scan

or

disp

lay

grap

hics

, rec

ord

or p

lay

soun

ds, o

r ty

pe m

essa

ges

whi

ch c

ould

cau

se

offe

nce

to o

ther

s x.

re

mov

e im

med

iate

ly f

rom

the

scr

een

any

mat

eria

l th

at w

ould

not

be

allo

wed

at

scho

ol w

hich

I m

ay

acci

dent

ally

com

e ac

ross

, and

adv

ise

the

teac

her i

mm

edia

tely

xi

. no

t use

any

dis

cs o

r CD

s fr

om h

ome

on s

choo

l com

pute

rs

3. I u

nder

stan

d I n

eed

to b

e re

spon

sibl

e fo

r priv

acy

and

secu

rity

i. I

will

not

giv

e an

yone

on

the

inte

rnet

, in

form

atio

n ab

out

mys

elf

or a

nyon

e el

se.

Thi

s in

clud

es

addr

esse

s, p

hone

num

bers

, pho

togr

aphs

and

/or c

redi

t car

d in

form

atio

n ii.

I w

ill a

dvis

e th

e te

ache

r if I

com

e ac

ross

a v

irus

or s

ecur

ity p

robl

em

Stud

ent:

I und

erst

and

and

will

abi

de b

y th

e ab

ove

agre

emen

t. I

acce

pt th

at if

I vi

olat

e an

y of

the

abov

e te

rms

or c

ondi

tions

in t

his

Agr

eem

ent,

scho

ol d

isci

plin

ary

actio

n m

ay b

e ta

ken

and/

or le

gal a

ctio

n m

ay b

e ta

ken.

__

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

____

____

____

____

____

____

____

____

____

___

S

tude

nt’s

Nam

e (in

full)

S

tude

nt’s

sig

natu

re

Pa

rent

/Car

egiv

er U

nder

taki

ng

As

pare

nt/g

uard

ian

of th

is s

tude

nt I

have

read

the

Term

s an

d C

ondi

tions

for I

nter

net a

cces

s. I

und

erst

and

that

th

is a

cces

s is

des

igne

d fo

r ed

ucat

iona

l pur

pose

s an

d th

at G

lenf

ield

Int

erm

edia

te S

choo

l has

tak

en a

vaila

ble

prec

autio

ns to

elim

inat

e co

ntro

vers

ial m

ater

ial.

(Gle

nfie

ld In

term

edia

te S

choo

l sub

scrib

es to

N4L

who

blo

ck

unsu

itabl

e si

tes

for o

ur u

sers

). H

owev

er, I

als

o re

cogn

ise

it is

impo

ssib

le fo

r Gle

nfie

ld In

term

edia

te S

choo

l to

rest

rict a

cces

s to

all

cont

rove

rsia

l mat

eria

ls a

nd I

will

not

hol

d th

e sc

hool

or i

ts s

taff

resp

onsi

ble

for a

ny m

ater

ial

acqu

ired

on th

e ne

twor

k.

I fur

ther

und

erst

and

that

acc

ess

to th

is s

ervi

ce m

ay b

e de

nied

if th

e te

rms

and

cond

ition

s of

the

Agr

eem

ent a

re

brea

ched

. __

____

____

____

____

____

____

____

____

____

__

____

____

____

____

_

Par

ent /

Car

egiv

er s

igna

ture

D

ate

✁

✁G

lenfield Intermediate S

chool

YH/Prospectus/Online Publication

Online Publication of Student Im

ages Rational The school uses a range of learning technologies to enhance student learning. These include electronic mail (email) and the Internet. From time to time, we publish on the school’s Internet website, material for educational purposes, to share the results of learning within the school community, and to promote the school within the wider community. This may include examples of students’ schoolwork and images of students and groups of students in activities at the school. Images of students may include scanned, digital, or video images of them taking part in school or class activities. Purpose There are three main reasons the school publishes student material online: i.

to educate the student in accordance with the national curriculum, including the role and use of technology in society; ii.

to encourage the student to be part of and participate in the school community; and iii.

to promote the school in the wider community. Guidelines 1.

The school will publish the material only on its own website and New Zealand based websites endorsed by the Ministry of Education. 2.

The school acknowledges that it cannot control who accesses the website on which students’ images or material is published or the copying, by visitors to these websites, of images of the students and their work.

3. The school will identify students on the websites only by their first name and year at school. Students’ surnames, home addresses and telephone numbers will not be available on the websites.

4. The school will not publish material online that may defame anyone, be objectionable from a human rights point of view, be obscene, or infringe the copyright of third parties. All the student material published online will be subject to an editing process, which will include the correction of spelling and grammatical errors.

5. The school has a designated privacy officer who is available to answer any enquiries from parents or students about the operation of the school’s policy for the online publication of student images and work.

Parent Perm

ission, for the Online Publication of a Prim

ary Student’s Image and W

ork

I ________________________________________name of Parent /Legal G

uardian) have read and understand G

lenfield Intermediate School’s policy on the Internet publication of student

images, student w

ork and student name, and the guidelines contained in the policy.

A

s the Parent or Legal Guardian of ___________________________________(full nam

e of Student) I authorise G

lenfield Intermediate School to publish

images of the student on the Internet,

work that he or she m

ay create at school student’s first nam

e and last name initial eg. Sam

P and year at school in strict com

pliance with the school’s policy for the online publication of student im

ages, work and nam

e, and the associated guidelines. I agree that this consent shall continue until I w

ithdraw m

y consent by notice to the school or until the student ceases to be enrolled in the school, w

hichever occurs first.

I confirm I have the necessary authority to give this perm

ission.

__________________________________ Date: __________________

Signature of Parent or Legal Guardian

I DO

NO

T give consent for the above. ___________________________________

Student’s nam

e ___________________________________

Date: __________________

Signature of Parent or Legal Guardian