Student Name (Last name, first name)
Parent Name (Last name, first name)
Grade
Address
Home Phone
School
City, Zip Code
Parent/Guardian Work Phone
Teacher (Grades K-5 only)
After reviewing the Facts for Parents booklet, student and parent/guardian must check each section, sign the last section, and return this form to the school office.
1.
DISCRIMINATION, HARASSMENT, INTIMIDATION, & BULLYING POLICIES
(Facts for Parents: Section B)
By checking each square and signing below, I acknowledge the following:
My student and I have read and understand the Discrimination and Harassment Policies
section.
My student and I understand the consequences should my student violate the policy.
I have been informed of these rights.
3. UNIFORM DISCIPLINE PLAN (Facts for Parents: Section C)
I acknowledge that my student has read the Uniform Discipline Plan, and that my student
and I understand the consequences should my student violate the policy.
4. HEALTH REQUIREMENTS (Facts for Parents: Section D)
California law requires that parents/guardians of each pupil acknowledge having been informed of their
rights as explained in “Health Requirements” in Facts for Parents.
I acknowledge that I have been informed of these rights.
2. PHOTOGRAPHY/VIDEO/MEDIA RELEASE*
During the school year, schools host events where representatives of the news media may be on
campus to gather photographs and/or video footage.
In addition, parents and students may take photos of events in classrooms or around schools. These
photos may be posted on the Internet, on social media or otherwise distributed without the
permission of the school. Your child’s participation in these events is valued, and parent
permission is needed to include him or her in events where photography may take place.
Parents/Guardians who prefer that their child not be photographed or video recorded must notify
their school by using this form. Schools make every effort to ensure the wishes of the
parent/guardian. Please be aware that photographing and video recording by devices such as a
mobile phones may take place without the knowledge of the teacher, principal or district staff.
PARENTS OR GUARDIANS:
Indicate your level of permission OR use the last circle to opt out completely.
I give my permission (select all that apply).
To have my student interviewed, photographed, and/or video recorded by news media.
To have my student photographed and/or video recorded by the district/school. Photos
and videos may be used on school/district websites, brochures, social media, etc.
To have my child’s name published in order to credit his or her work.
To have my student’s photograph included in the school yearbook.
I DO NOT want my child’s name, photo or video published publicly.
5. TECHNOLOGY/NETWORK USE GUIDELINES (Facts for Parents: Section K)
The “Network Use Guidelines” for San Diego Unified School District is a contract and must be signed
by students and parent/guardians before the student is given access to technology, the internet and other
San Diego Unified networks.
STUDENT: I understand and will abide by the rules and conditions outlined in Section K
about access to technology, the internet and other San Diego Unified networks.
PARENT or GUARDIAN: I give my student permission to use technology, and access the
internet and other San Diego Unified networks.
6. SIGNATURES
By completing sections 1 5 and signing below, I the student, and I the parent, have read, understand
and acknowledge the policies and rights outlined above and described in detail in Facts for Parents.
Student Signature (print student name to sign)
Date
Parent/Guardian Signature (print guardian name to sign)
Date
Universal Form
Signature Verification of Receipt of Documents/Release of Information
* Update your release preferences at any time by contacting your school office
Revised: July 2020
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