RIDGEFIELD SCHOOL DISTRICT 122 STUDENT REGISTRATION FORM

FOR OFFICE USE

Start Date:

Key Pad #: PLEASE COMPLETE ALL 4 PAGES

STUDENT NAME: Legal Last Legal First Legal Middle Other Name Used Grade Level

BIRTHDATE (Month/Day/Year) BIRTHPLACE (City/State/Country) GENDER

Male Female PREVIOUS SCHOOL ATTENDED (Name/District) City State Did student

formally withdraw? Yes No

Withdraw Date:

If enrolling from out of state, has student ever attended Washington State Public Schools?

Yes No

Has student ever attended Ridgefield Public Schools? Yes No

Name of School: Grades Attended:

PRIMARY HOUSEHOLD WHERE STUDENT RESIDES PARENT/GUARDIAN Last Name First Name

Email Address

PRIMARY PHONE FOR NOTIFICATIONS ( )

Primary phone is: Home Cell

STUDENT RESIDES WITH

Both parents Father only Mother only Joint Custody Grandparent(s) Father/Stepmother Mother/Stepfather Other Family Member Legal Guardian Self Agency Foster Home Other (specify)

______________________

Home Phone

Cell Phone

Work Phone

( )

( )

( )

Last Name First Name

Email Address

Cell Phone

Work Phone

( )

( )

PHYSICAL ADDRESS WHERE FAMILY RESIDES – Required City State Zip

MAILING ADDRESS – If different from physical address City State Zip

USE THIS SECTION TO PROVIDE INFORMATION FOR STUDENTS WITH A SECOND HOUSEHOLD SECOND HOUSEHOLD CONTACTS Last Name First Name

Email Address

Relationship to student Home Phone

Cell Phone

Work Phone

( )

( )

( )

Last Name First Name

Email Address

Cell Phone

Work Phone

( )

( )

Relationship to student

SECOND HOUSEHOLD ADDRESS City State Zip

MAILING ADDRESS City State Zip

IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? Yes No (provide copy to school)

IS THERE A RESTRAINING ORDER IN EFFECT? Yes No (provide copy to school) RESTRAINING ORDER AGAINST: Father Mother Other:_____________________________

IS THERE A LEGAL RESTRICTION PREVENTING THE NON-CUSTODIAL PARENT FROM VISITING THE SCHOOL OR REMOVING THE STUDENT FROM THE SCHOOL: Yes No (provide copy to school)

SEND COPIES OF REPORT CARDS TO SECOND HOUSEHOLD? Yes No

Is any parent or guardian a member of the military? Yes No parent or guardian is an active duty member of the U.S. Armed Forces parent or guardian is a member of the reserves of the U.S. Armed Forces parent or guardian is a member of the Washington National Guard more than one parent or guardian is a member of any of the above

Page 1 of 4 Administrative Procedure Form Policy 3120 Revised 03.21.2016

ETHNICITY AND RACE PLEASE ANSWER BOTH QUESTIONS 1 AND 2

BOTH RESPONSES ARE PER WASHINGTON STATE AND FEDERAL REQUIREMENTS Question 1: Is your child of Hispanic or Latino origin? (check all that apply)

Answer: NOT HISPANIC

CENTRAL AMERICAN CUBAN

DOMINICAN LATIN AMERICAN MEXICAN / CHICANO /

MEXICAN AMERICAN

PUERTO RICAN SOUTH AMERICAN SPANIARD OTHER HISPANIC / LATIN

Question 2: What race do you consider your child?

(Check all that apply)

Answer: AFRICAN AMERICAN / BLACK

WHITE / CAUSCASIAN

ASIAN INDIAN CAMBODIAN CHINESE FILIPINO HMONG INDONESIAN JAPANESE KOREAN LAOTIAN MALAYSIAN PAKISTANI SINGAPOREAN TAIWANESE THAI VIETNAMESE OTHER ASIAN

NATIVE HAWAIIAN FIJIAN GUAMANIAN or CHAMORRO MARIANA ISLANDER MELANESIAN MICRONESIAN SAMOAN TONGAN OTHER PACIFIC ISLANDER

ALASKAN NATIVE CHEHALIS COLVILLE COWLITZ HOH JAMESTOWN KALISPEL LOWER ELWHA LUMMI MAKAH MUCKLESHOOT

NISQUALLY NOOKSACK PORT GAMBLE CLALLAM PUYALLUP QUILEUTE QUINAULT SAMISH SAUK-SUIATTLE SHOALWATER SKOKOMISH SNOQUALMIE SPOKANE SQUAXIN ISLAND STILLAGUAMISH SUQUAMISH TULALIP YAKIMA OTHER WASHINGTON

INDIAN

OTHER AMERICAN INDIAN

EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of an accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child.

Parent/Guardian Signature __________________________________________________________________ Date _________________________

If injury, illness or other nonemergency situations occur involving your child, the District needs to be able to quickly reach families or other responsible adults. In the event you cannot be reached, please list persons you trust who are available during the day to provide care for your child (local area only please).

Student Release Authorization: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed below.

Parent/Guardian Signature __________________________________________________________________ Date _________________________

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone

Cell Phone

Work Phone

( )

( )

( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone

Cell Phone

Work Phone

( )

( )

( )

DOES STUDENT ATTEND CHILD CARE? Before school

Yes No After school

CHILD CARE PROVIDER (Name/address/phone number)

Page 2 of 4 Administrative Procedure Form Policy 3120 Revised 03.21.2016

STUDENT PROGRAMS/ADDITIONAL INFORMATION Are there any school activities in which your student should not participate?

Yes No If yes, parent/guardian must provide documentation regarding reasons for non-participation.

Does student have a Boundary Exception?

Yes No

Has student ever been retained? Yes No Grade? ______________

Indicate if student has ever been enrolled in the following programs:

Special Education Speech/Language OT/PT 504 Plan Title/Lap Reading Title/Lap Math Transitional Bilingual Gifted Other

Yes No If yes: Current IEP Exited Program Yes No If yes: Current IEP Exited Program Yes No If yes: Current IEP Exited Program Yes No If yes: Current Plan Yes No If yes: Currently receiving services Yes No If yes: Currently receiving services Yes No If yes: Currently receiving services Yes No If yes: Currently receiving services Yes No Specify: ___________________________

Does student have a probation officer or case worker? Yes No Name: ______________________________________

Has student ever been suspended for a weapons violation? Yes No Date: _______________________________________

STUDENT RESIDENCY The following question can help determine the services your student may be eligible to receive under the Title 1 Part A and/or Federal McKinney-Vento Act 42 U.S.C. 11435. Eligibility can be determined by completing this confidential questionnaire. The purpose of this information is to ensure the rights of your student/s under the McKinney-Vento Act. This information is confidential. Is the student’s home address a temporary living arrangement? Is this a temporary living arrangement due to a loss of housing or economic hardship? Is the student in a temporary foster care placement or awaiting foster care? As a student, are you living with someone other than your parent or legal guardian? Unknown nighttime residence? Is the student an unaccompanied youth?

Yes No Yes No Yes No Yes No Yes No Yes No

If you answered NO to all of the above Student Residency questions, you may stop this section here. If you answered YES to any of the above Student Residency questions, please complete the remainder of this section.

Student is currently living: In a motel In a shelter Doubled up with one or more other families

In a location not designed for sleeping accommodations (ex: car, park, campsite)

Other: ADDRESS OR GENERAL AREA OF CURRENT RESIDENCE City State Zip

NAME OF MOTEL/SHELTER NAME/PHONE NUMBER OF CONTACT DATE STUDENT BEGAN LIVING HERE

ARE THERE ANY SIBLINGS ENROLLED IN RIDGEFIELD PUBLIC SCHOOLS RESIDING HERE ALSO? PROVIDE NAME(S) AND SCHOOL:

REGISTRAR: If the answer to at least one of the Student Residency questions is Yes, contact the District Homeless Liaison.

Verification of information: The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Ridgefield School District.

____________________________________________________________________________________ _______________________ Parent/Legal Guardian/Adult Student Signature Date

This form contains public information. To request withholding of all or part of this information (opt-out) pursuant to the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. 1232g; 34 CFR 99), complete a “Nondisclosure Form” annually. Forms are available at the school office or online at www.ridgefieldsd.org

Ridgefield School District #122 complies with all state and federal rules and regulations and provides equal opportunity in programs and employment and does not unlawfully discriminate on the basis of race, color, national origin/language, marital status, HIV/Hepatitis C status, sex, sexual orientation-including gender expression or identity, creed, religion, age, veteran or military status, disability, or the use of a trained dog guide or service animal by a person with a disability, and provides equal access to the Boy Scouts of America and other designated youth groups. Ridgefield School District will also take steps to assure that national origin persons who lack English language skills can participate in all education programs, services and activities. For information regarding translation services, bilingual education or inquiries regarding compliance procedures, contact Chris Griffith, Title IX/Section 504/ADA Coordinator, 2724 S. Hillhurst Road, Ridgefield, WA 98642, (360) 619-1300, or by email at

chris.griffith@ridgefieldsd.org

Page 3 of 4 Administrative Procedure Form Policy 3120 Revised 03.21.2016

Office of Superintendent of Public Instruction (OSPI) Washington State Transitional Bilingual Instructional Program Home Language Survey

Student Name: Date:

Birth Date: Gender: Grade: SSID: (For Office Use Only)

Form Completed by: Parent/Guardian Name Relationship to Student Parent/Guardian Signature

If available, in what language would you prefer to receive communication from the school?

Did your child receive English language development support through the Transitional Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__

1. In what country was your child born? _____________________

2. What language did your child first learn to speak?* _____________________

3. What language does YOUR CHILD use the most at home?* _____________________

4. What language(s) do parent/guardians use the most when you speak to yourchild?

_____________________ _____________________

5. Has your child ever attended a school outside of the United States?

_____Yes _____No

If yes, in what language(s) was instruction given? _____________________ For how many months? ____

6. Has your child attended school in the United States before enrolling in thisdistrict? (Kindergarten – 12th grade)

_____Yes _____No

For how many months? ________ months *One (1) school year =10 months

7. Do grandparent(s) or parent(s) have a tribal affiliation?

_____Yes _____No

*WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by parents, guardians, or others)for communication in the student's place of residence.

.

Page 4 of 4 Administrative Procedure Form Policy 3120 Revised 03.21.2016

RIDGEFIELD SCHOOL DISTRICT NO. 122

Administrative Procedure Form 3231 Revised: 12.20.07

Request for Authorization of Release of Student Records

Student Legal Name ____________________________________________ Birth Date ____/____/___ Grade ___ Last First Middle

Other Name(s) Used By Student _______________________________________________________________________________

Student Address______________________________________________________________________________ Street/PO Box City/State Zip Code

Student Home Phone No. ___________________________ Alternate Phone No._________________________

I hereby authorize release of student records for the above-named student as follows:

Transferring From School: ________________________________________________

School Address______________________________________________________________________________ Street/PO Box City/State Zip Code.

Phone No __________________________________ Fax No. ______________________________________

The cumulative records and confidential information include but are not necessarily limited to the following: _______ Scholastic Achievement Data (including transcript of credits and grades at time of withdrawal) _______ Standardized Test Data _______ Medical Data _______ Psychological Data _______ Sociological Data _______ Discipline Records _______ Specialized Education Records

a. Current IEPb. Initial Placementc. 3 Year Evaluation

_______ 504 _______ Other

I understand that this information will be kept confidential and will be used for educational placement purposes. (In order to secure a transcript or other school records from your child’s previous school, we are required to obtain your written permission prior to making such a request.)

_________________________________________________________________________/____/_____ Parent/Legal Guardian/Adult Student Date

Transferring To School:

________________________________________________________________________________/____/_____ Registrar/Secretary Date

WHITE: Transferring From School YELLOW: Transferring To School PINK: Specialized Student Services

___ Ridgefield High School 2630 S. Hillhurst Road, Ridgefield WA 98642 Ph: 360-619-1320 Fax: 360-619-1395___ View Ridge Middle School 510 Pioneer Street, Ridgefield WA 98642 Ph: 360-619-1400 Fax: 360-619-1459___ South Ridge Elementary 502 NW 199th Street, Ridgefield WA 98642 Ph: 360-619-1500 Fax: 360-619-1559___ Union Ridge Elementary 330 N. Fifth Street, Ridgefield WA 98642 Ph: 360-750-7600 Fax: 360-750-7659

Parent/guardian signature: _____________________________________________Date:___________________

Ridgefield School District

Student Health History 2016-17To be completed by parent/guardian

Student Name: _____________________ Date of Birth: _________________Grade: ____ Male Female

Parent Name: _______________________Phone #: ___________________Teacher: __________Bus#____

INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH

ANY OF THE FOLLOWING:

If your child has a life-threatening condition, state law requires a medication and/or treatment orders from a

Licensed Health Professional and an Emergency plan must be in place before your child can attend school.

See office for forms. Please check appropriate boxes below and explain if needed

Health Condition Yes No Explanation if “Yes” checked

Food Allergies

Food(S): peanut tree nut dairy eggs other_________

Rate the reaction: mild moderate life-threatening

Does your child require an EpiPen? yes no

Is this allergy a food sensitivity? yes no Please describe symptoms:

Allergy to Bee Stings Rate the reaction: mild moderate life-threatening

Describe the reaction:_______________________________________

Does your child require an EpiPen? yes no

Medication Allergies List:

Allergies (other) List:

Asthma

Rate the severity: mild moderate life-threatening

Asthma medication taken at home:___________________________

Medication required at school:_______________________________

Last asthma attack:_______________________________________

Diabetes Type 1 (insulin Dependent) Type 2

Diabetes medications(s) taken at home:

Seizure Disorder Type of seizure: Medications:

Heart Condition Specify:

Cancer Specify:

Blood Disorder Specify: Treatment:

ADD/ADHD Medication for ADD/ADHD:

Mental Health /

Behavioral Issues Specify:

Treatment/Medication:

Orthopedic Condition Specify:

Wears glasses For Distance For Reading

Hearing Loss Hearing Loss Right Ear Left Ear Hearing Aids

Headaches/migraines

Head Injury

Please Describe:

Other: Describe:

Does your child have any other condition that would affect his/her classroom

performance or P.E. activities? No Yes if yes, explain: _________________________________________________________

Daily Medication

State law requires written permission from a Licensed Health Professional and parent before any

medication (prescription or over-the-counter) can be given at school. A form is available from the school office.

No Yes Medication needed at school- specify: __________________________

No Yes Medication needed at home- specify: ___________________________ This information is considered confidential. It will be shared with school staff and emergency responders as needed during the time your

child is enrolled in Ridgefield School District in order to ensure the health and safety of your child, unless otherwise requested by you in

writing.

STUDENT ACCESS TO NETWORKED INFORMATION RESOURCES Procedure 2022F

Date: 10.23.01; 11.27.07; 08.10; 05.12; 02.28.13; 08.20.13

ACCEPTABLE USE POLICY (AUP) AGREEMENT FOR STUDENTS

The Ridgefield School District is pleased to offer our students access to the district computer networks for electronic mail and the Internet. To gain access to e-mail and the Internet, all students under the age of 18 must obtain parental permission and must sign and return this form to the LIBRARY MEDIA SPECIALIST. Students 18 and over may sign their own forms. Access to e-mail and the Internet will enable students to explore thousands of libraries, databases, and bulletin boards while exchanging messages with Internet users throughout the world. Families should be warned that some materials accessible via the Internet may contain items that are illegal, defamatory, inaccurate or potentially offensive to some people. While our intent is to make the Internet access available to further educational goals and objectives, students may find ways to access other materials as well. We believe that the benefits to students from access to the Internet, in the form of information resources and opportunities for collaboration, exceed any disadvantages. But ultimately, parents and guardians of minors are responsible for setting and conveying the standards that their children should follow when using media and information sources. To that end, the Ridgefield Schools support and respect each family's right to decide whether or not to apply for access.

District Internet and E-Mail Rules:

Students are responsible for good behavior on school computer networks just as they are in a classroom or a school hallway. Communications on the network are often public in nature. General school rules for behavior and communications apply.

The network is provided for students to conduct research and communicate with others. Access to network services is given to students who agree to act in a considerate and responsible manner. Parent permission is required. Access is a privilege-not a right. Access entails responsibility and users waive any rights to privacy which they would otherwise have regarding such material. All network activity and content will be filtered to the best of the district’s ability.

Individual users of the District computer networks are responsible for their behavior and communications over those networks. It is presumed that users will comply with District standards and will honor the agreements they have signed. Beyond the clarification of such standards, the district is not responsible for restricting, monitoring or controlling the communications of individuals utilizing the network.

Network storage areas may be treated like school lockers. Network administrators may review files and communications to maintain system integrity and ensure that users are using the system responsibly. Users should expect that files stored will not be private and will be filtered through district network filtering.

Within reason, freedom of speech and access to information will be honored. During school, teachers of younger students will guide them toward appropriate materials. Outside of school, families bear the same responsibility for such guidance as they exercise with information sources such as television, telephones, movies, radio and other potentially offensive media.

As outlined in Board policy and procedure 2022 on

students rights and responsibilities, the following are some

examples of the things not permitted and considered

Network and Internet Offenses: •Sending or displaying offensive messages or pictures •Using obscene language •Harassing, insulting or attacking others •Damaging computers, computer systems or computer networks •Violating copyright law •Using another's password •Trespassing in another's folders, work or files •Intentionally wasting limited resources •Employing the network for commercial purposes • Bypassing or sabotaging security and filtering measures set in place by the District. • Attaching any unauthorized equipment to the network.

NOTICE: Violations of Network and Internet offenses

may result in a loss of access as well as other disciplinary

or legal action.

THIS FORM HAS TWO SIDES. PLEASE READ BOTH SIDES BEFORE SIGNING.

STUDENT ACCESS TO NETWORKED INFORMATION RESOURCES Procedure 2022F

Date: 10.23.01; 11.27.07; 08.10; 05.12; 02.28.13; 08.20.13

ACCEPTABLE USE POLICY (AUP) AGREEMENT FOR STUDENTS

As part of the Internet and Network access provided by Ridgefield School District, students are allowed to connect personal devices to the districts Bring Your Own Device (BYOD) network. The following rules and responsibilities should be followed and taken into consideration by parents before allowing the student to bring personal devices into the school district.

District Rules and Responsibilities concerning

use of personal devices:

The student takes full responsibility for his or her device and keeps it with him or her at all times. The school or District is not responsible for the technical support or the security of the device.

The student is responsible for the proper care of their personal device, including any costs of repair, replacement, or any modifications needed to use the device at school.

The school reserves the right to inspect a student’s personal device if there is reason to believe that the student has violated Board policies, administrative procedures, school rules, or has engaged in other misconduct while using their personal device.

Violations of any Board policies, administrative procedures, or school rules involving a student’s personally owned device may result in the loss of use of the device in school and/or will be subject to disciplinary action.

The student must comply with teachers’ request to shut down the computer or put the device away entirely.

The student may not use the devices to record, transmit, or post photos or video of a person or persons on campus. Nor can any images or video recorded at school be transmitted or posted any time without the express permission of a teacher.

The student should only use their device to access resources relevant to their courses.

The student will use the District’s secured wireless network. Use of 3G and 4G wireless connections is not allowed.

If you’d like your child to have access to the Ridgefield wireless guest network using a personal device, please clip, fill-out and return the bottom portion of this form to the office at your child’s school..

Student User Agreement / Parent Permission As a user of the Ridgefield School District computer network, I hereby agree to comply with above stated rules - communicating over the network in a reliable fashion while honoring all relevant laws and restrictions. _______________________________ __________________________________ ____________________ STUDENT LEGAL NAME (print) STUDENT SIGNATURE DATE _______________________________ __________________________________ ____________________ PARENT NAME (print) PARENT SIGNATURE DATE

OPT OUT: I have read this form and do NOT want my child to have Internet Access: ______________ (Parent Initials)

OPT OUT: I have read this form and do NOT want my child to have BYOD Access: ______________ (Parent Initials)

Opting out of BYOD Access does not remove the student’s responsibility to comply with Rules and Responsibilities

that concern personal devices. It is the responsibility of the parent to prevent the student from bringing devices into

the district if the parent does not agree to the responsibilities listed above.

THIS FORM HAS TWO SIDES. PLEASE READ BOTH SIDES BEFORE SIGNING.

RIDGEFIELD SCHOOL DISTRICT

PARENTAL RIGHTS UNDER THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)

ANNUAL NOTICE

The Family Educational Rights and Privacy Act (FERPA), a federal law, affords parents or guardians

(and students over 18 years of age or who attend postsecondary educational institutions, known as

“eligible students”) certain rights with respect to their student’s education records. Under FERPA,

parents/guardians or eligible students have a right to:

1. Inspect and review the student’s education records within 45 days after the day the District

receives a request for access. Parents or eligible students who wish to inspect their child’s or

their education records should submit to the student’s school a written request that identifies

the record(s) they wish to inspect. The records custodian will make arrangements for access

and notify the parent or eligible student of the time and place where the records may be

inspected.

2. Request the amendment of the student’s education records that the parent or eligible student

believes are inaccurate or misleading, or otherwise in violation of the student’s privacy rights

under FERPA. Parents or eligible students who wish to ask the District to amend their child’s

or their education record should write the school principal, clearly identify the part of the

record they want changed, and specify why it should be changed. If the District decides not to

amend the record as requested by the parent or eligible student, the District will notify the

parent or eligible student of the decision and of their right to a hearing regarding the request

for amendment. Additional information regarding the hearing procedures will be provided to

the parent or eligible student when notified of the right to a hearing.

3. Provide written consent before the school discloses personally identifiable information (PII)

from the student’s education records, except to the extent that FERPA authorizes disclosure

without consent (such as for “directory information,” described below).

One exception, which permits disclosure without consent, is disclosure to school officials

with legitimate educational interests. The criteria for determining who constitutes a school

official and what constitutes a legitimate educational interest must be set forth in the school’s

or school district’s annual notification for FERPA rights. A school official typically includes

a person employed by the school or school district as an administrator, supervisor, instructor,

or support staff member (including health or medical staff and law enforcement unit

personnel) or a person serving on the school board. A school official also may include a

volunteer, contractor, or consultant who, while not employed by the school, performs an

institutional service or function for which the school would otherwise use its own employees

and who is under the direct control of the school with respect to the use and maintenance of

PII from education records, such as an attorney, auditor, medical consultant, or therapist; a

parent or student volunteering to serve on an official committee, such as a disciplinary or

grievance committee; or a parent, student, or other volunteer assisting another school official

in performing his or her tasks. A school official typically has a legitimate educational interest

if the official needs to review an education record in order to fulfill his or her professional

responsibility.

Ridgefield School District FERPA Annual Notice Page 2/3

Upon request, the District discloses educational records without consent to officials of

another school district in which a student seeks or intends to enroll, or is already enrolled if

the disclosure is for purposes of the student’s enrollment or transfer.

Requests from prospective employers to review the transcript of a student will be honored

only upon a signed release of the parent/guardian or eligible student.

4. File a complaint with the U.S. Department of Education concerning alleged failures by the

District to comply with the requirements of FERPA. The name and address of the Office that

administers FERPA is:

Family Policy Compliance Office

U.S. Department of Education

400 Maryland Avenue S.W.

Washington, D.C. 20202

Directory Information

FERPA requires that the District, with certain exceptions, obtain your written consent prior to the

disclosure of personally identifiable information from your child’s education records. However, the

District may disclose appropriately designated “directory information” without written consent,

unless you have advised the District to the contrary in accordance with District Procedure 3231P.

The District has designated the following information as directory information:

Student name; parent/guardian name(s); address; telephone number; electronic mail (email)

address; photograph; video; images; audio recordings; date and place of birth; dates of

attendance; grade level; participation in officially recognized activities and sports; weight and

height of members of athletic teams; degrees, honors, and awards received; and the most

recent educational agency or institution attended.

The District may release directory information to anyone, including but not limited to parent-teacher

organizations, the media, colleges and universities, the military, youth groups, and scholarship

grantors, unless you tell us that you do not want the information released (see below for instructions

on how to opt out of sharing directory information).

The actual residential addresses of participants in the state Address Confidentiality Program will not

be available for release as directory information. Social Security numbers, student identification

numbers (with authentication factors such as a secret password or personal identification number), or

other personally identifiable information are not considered directory information.

The purpose of directory information is to allow the District to include information from a student’s

education records in certain school publications and to promote the District’s education mission. For

example, directory information may be used for purposes including, but not limited to:

District, school, or class newsletters and other printed or electronic official

publications;

Articles on the District’s website, including blogs;

District-operated social media pages, such as on Facebook, Instagram, or Twitter;

News releases to area newspapers, TV stations, or other media;

Ridgefield School District FERPA Annual Notice Page 3/3

A playbill, showing a student’s role in a drama production;

The annual yearbook;

Honor roll or other recognition lists;

Graduation programs; and

Sports activity sheets, such as for wrestling, showing weight and height of team

members.

In addition, two federal laws1 require local educational agencies (LEAs) receiving assistance under

the Elementary and Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon

request, with three directory information categories—names, addresses, and telephone listings—

unless parents have asked the LEA not to disclose this information without their prior consent.

Instructions to Request Opt-Out of Directory Information

Under FERPA, you have the right to opt out of disclosure of any or all directory information, as

described above, regarding your student. If you wish to opt out, you must notify the District in

writing no later than August 15 of the current school year, or at the time of enrollment if after August

15. A request to opt out lasts for the current year only; a new request is required each year. To opt

out, complete and return the District form entitled “Request to Opt Out of FERPA Directory

Information.” In the alternative, you may provide a dated, written statement (typed or legibly printed)

that includes all of the following information:

Full name of student;

Grade level for the current school year;

Specific item(s) that you do not want to be considered as “directory information” for your

child for the current school year;

If applicable, a specific request of non-disclosure of information to military recruiters;

Parent/guardian or eligible student name; and

Parent/guardian or eligible signature.

The opt-out form or other written request to opt-out of directory information must be delivered to the

following office: Khristy McRobert, Ridgefield School District, 2724 South Hillhurst

Road, Ridgefield, Washington 98642.

NOTE: Additional information about the District’s policies and procedures for maintenance

and disclosure of student records is available in Board of Directors Policy 3231 and Procedure

3231P, which are available on the District’s website at www.ridgefieldsd.org.

1 These laws are: Section 9528 of the ESEA (20 U.S.C. 7908), as amended by the No Child Left Behind

Act of 2001 (P.L. 107-110), the education bill, and 10 U.S.C. 503, as amended by section 544, the

National Defense Authorization Act for Fiscal Year 2002 (P.L. 107-107).

REQUEST TO OPT OUT OF FERPA DIRECTORY INFORMATION 2016-2017

As described in the District’s annual notification provided to families (entitled “Parental Rights

Under the Family Educational Rights and Privacy Act (FERPA)”) and District Procedure 3231P,

parents/guardians (or eligible students) have the right to request that the District not disclose

information from their student’s education records designated as “directory information” without

prior consent.

If you consent to the District sharing directory information about your student, there is no

need to take any action. However, if you wish to opt out pursuant to FERPA, please complete

this form and return it to your child’s school no later than August 22, 2016, or at the time of

enrollment if after August 22. If this form is not completed and filed with the District, the

District may disclose directory information about your student for the remainder of the current

academic year without your prior consent as described in the annual notice. You may revoke this

opt-out form in writing by filing consent to disclosure of directory information with the school

office.

________________________________________________________________

Student Last Name First Name Middle Name

________________________________________________________________

School Attended Grade

CHECK ONLY ONE BOX:

Do not disclose any directory information about the above-named student during the 2016-

17 school year, except as authorized by law.

The District may disclose directory information about the above-named student, except

information may NOT be released to the military unless otherwise authorized by law.

________________________________________________________________

Parent/Guardian/Eligible Student Name Signature Date

Return this form to your student’s school office no later than August 22, 2016, only if you

are opting out of directory information.

AUTOMATED COMMUNICATIONS (SCHOOLMESSENGER) NOTIFICATION

Consent to Receive Automated Communications

The Ridgefield School District (“District”) uses SchoolMessenger, an automated system, to

make important school-related announcements in the form of calls and text messages to the

cellphone and residential telephone numbers of parents/guardians and students. Those

communications include messages about snow days, other school cancellations, student

absences, and school events.

By providing telephone numbers on and signing student registration paperwork, you consent to

receive automated text messages and calls from the District at those numbers. You may opt not

to receive such automated messages (other than emergency messages) by submitting the form

below to Khristy McRobert at the District Office, or by providing notice to Khristy McRobert at

360-619-1309 or khristy.mcrobert@ridgefieldsd.org.

(Separate and return this form to opt out of automated messages.)

Request Not to Receive Automated Messages

Although the District requests that parents/guardians and students consent to receive automated

messages as described above by providing telephone contact information on registration

paperwork, you may opt out of receiving automated text messages and phone calls (other than

emergency messages) by completing the information below:

I opt out of receiving automated (check all that apply) text messages telephone calls from

the District at the following numbers (list all numbers that apply, including area codes):

1. ____-________________ Cellphone Residential line

2. ____-________________ Cellphone Residential line

3. ____-________________ Cellphone Residential line

4. ____-________________ Cellphone Residential line

Your decision to opt out will be effective unless you notify us otherwise in writing. Note that the

law allows the District to make automated emergency calls (such as about school lockdowns) to

telephone numbers you have provided regardless of whether you opt out of other messages.

Please return this form to Khristy McRobert.

You may also opt out by contacting Khristy McRobet at 360-619-1309 or

khristy.mcrobert@ridgefieldsd.org.