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NorthStar Consent and Agree

Agree and Consent^*

I have read, understand and consent to the Terms and Conditions in the Declarations below.

Declaration Agree and Consent Release and Agree My child is joining NorthStar with my consent. I hereby release NorthStar, its Board of Directors, agents, contractors, and employees from an and all claims, causes of action, liability, suits, or demands for compensation for injuries or property damage resulting from a) my child taking part in and or assisting with any NorthStar activities, or b) designated NorthStar personnel administering emergency medical treatment as authorized in the Emergency Medical Treatment section. Transportation Consent NorthStar provides transportation from targeted area schools to NorthStar and/or for field experiences with programming, athletics, or Outward Bound. Evaluation Consent I give permission for my son to participate in evaluation activities at NorthStar. These activities may include taking surveys, testing for skill development and/or knowledge, discussion groups, recorded observations of classroom participation, and other formal and informal activities designed to evaluate the effectiveness of the NorthStar experience. Media/Name Consent NorthStar utilizes photograph/videos and other media of the Students and their names in promotional material (websites, News Papers, Social Media etc.) Field Trip Consent In addition to regularly scheduled field trips, from time to time, NorthStar receives last minute tickets or admissions to local museums or events and we would like to take every advantage of these great opportunities. If you sign below, you give permission for your son to attend all field trips without a specifi permission slip. Students may receive a field trip fl er to inform parents of a scheduled field trip. Rules and Regulations for Members NorthStars rules for members are important. I will review the Membership Handbook’s basic rules with my child. Student Orientation I understand that attending Parent and Athletic Orientations is important and I agree to adhere to the policies of NorthStar as stated in the Parent Expectations/Procedures guide. I also agree to further review NorthStar policies with my son, and support the expectations for the appropriate behavior of my son while in attendance at NorthStar.

Consent to Release Student Records Omaha Public Schools^*

I give consent to the Omaha Public Schools to release all of the student information in the categories/examples listed below. I give consent to the Omaha Public Schools to release any additional student information approved by OPS in the future to the program and the United Way of the Midlands. (Signature and date required below). Student Demographic Information

The Omaha Public Schools (OPS) seeks to support students and families and to remove barriers to success in school. OPS works with Omaha area community organizations to provide district identified needs and student and family support programs. Organizations working with OPS are required to monitor and report student progress toward program goals. Program staff views student information stored by the United Way of the Midlands and by OPS. End of year data is provided and the program uses the information to monitor and evaluate their services. OPS must approve any research to study the impact of participation in this community program using the student information. The consent of a parent or a legal guardian of the student is required for OPS to release the requested student information from your child’s education records. Eligible students age 18 or older may consent to the release of their own student records. Student Demographic Information District, State ID Numbers Student Name, Date of Birth, Addresses Gender, Race, Ethnicity Home/Correspondence Language, ELL, LEP Enrollment, School, Grade Parent / Guardian Demographic Information Name, Relationship to Student, Address, Telephone Numbers Emergency Contact Information Name, Relationship to Student, Telephone Numbers This Consent to Release Student Records expires upon any of the following events, whichever comes first: Attendance Absences, Dates, Reasons Schedule / Grades / GPA Class Schedule, Grades, GPAs Transcripts/Credits District, State, and National Test Scores Not to include scores for internal OPS use only School and Program Staff Communication When my child no longer participates in the program, or (agency to inform OPS-SIS) When my child transfers from OPS, levels up from elementary to middle school, or middle to high school When OPS releases end of year data after one of the preceding events, or When a parent/guardian requests OPS Student Information Services to revoke the consent.

Private or parochial school Consent to Release Information^*

I give consent for my Childs Private or Parochial school to release his information.

This release may cover, but is not limited to: Report Cards Attendance Information Standard Test Results Teacher and Counselor Observations

Leave the Building

Permission to Leave the Building without and Authorized Adult

My son can leave the building without supervision

Leave blank if your son requires supervision when leaving the building. For safety reasons, we recommend that all parents come inside the building to pick up each child. If a parent chooses to have their child exit the building alone they must first complete the necessary paperwork. Parents who wish to have their child exit the building alone will need to call the main desk each time the student is to be dismissed all students must check out before they are allowed to leave. “I understand that I hold NorthStar Foundation, all respective offi ers, agents and employees, harmless from any and all liability or claims which may arise out of, or in connection with, my child’s participation in walking out of the building without an authorized adult."

Walk Home

By checking this box my son has permission to walk home without supervision.

In order for a student to walk home from NorthStar a parent must mark the, “YES” space below and must grant written permission for the student’s file “I understand that I hold NorthStar Foundation, all respective officers, agents and employees, harmless from any and all liability or claims which may arise out of, or in connection with, my child’s participation in walking out of the building without an authorized adult.

Email^*

BY TYPING YOUR FULL LEGAL NAME IN THE E-SIGN BOX YOU ARE ELECTRONICALLY SIGNING THIS DOCUMENT.

E-Sign Primary Parent/Guardian^*

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