✁
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