Application Submitter Full Name*
Custody Issues (optional)
Are there any custody issues that Student Hires should be aware of?
please note: by law, we can not refuse student release to a parent unless the court orders are on file in the school office.
If you answered yes above, please describe.
Student Demographic Information
Question #1: Is your student enrolled in the Free or Reduced Lunch Program? *
Question #2: Is your student designated as an English Learner (EL)? *
Question #3: Is your student designated as a Special Education Student with an Individualized Education Plan (IEP)? *
Question #4: Does your student have a 504 plan? *
Question #5: Does your child have any medical conditions, allergies, or other special needs or problems we should be aware of? *
If you answered yes to question 3, 4 or 5, please describe.
Student Ethnicity Information (optional)
Question 1: Are you Hispanic or Latino? (A Person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Question 2: What is your student's race?
Student Photo / Video / Work Release Authorization *
I hereby authorize Student Hires, its employees, and agents permission to use and publish work my student creates during Student Hires programs. In addition, I authorize Student Hires to use and publish photos and videos my student may appear in during Student Hires programs. The student work, photos, and videos may be used in publications, videos, social media, advertising, and any other manner without compensation to my child, myself, or other parents or guardians.
Student Information Release Authorization *
As part of my student’s participation in Student Hires programs, the school or school district may share my student’s data to assist Student Hires in understanding my student’s needs and making programming decisions. Student Hires is authorized to administer surveys & assessments to gather student data in its programs.
Medical Treatment Authorization
*
In the event of illness or serious injury, Student Hires is authorized to seek medical help and assistance by contacting emergency services for my student. I acknowledge that Student Hires is not responsible for providing medical coverage for my student.
Program Participation Agreement
*
As part of my student’s participation in Student Hires programs, the school or school district may share my student’s data to assist Student Hires in understanding my student’s needs and making programming decisions. Student Hires is authorized to administer surveys & assessments to gather student data in its programs.
Signature *
I hereby confirm that all information contained above has been answered to the best of my ability. To submit your application, please sign by typing in the full name of whoever filled out this application form.