Signature Page: Dance Agreement, Cell Phone Policy, Electronic Devices, Movie Permission, Email Permission, Technology Use, and Community Service



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PINER-OLIVET CHARTER SCHOOL Page 1

Signature Page: Dance Agreement, Cell Phone Policy, Electronic Devices, Movie Permission, Email Permission, Technology Use, and Community Service.




Student ___________________________________Grade_____ Homeroom Teacher _______________

Please Print – First & Last

RETURN THIS SIGNED TWO-PAGE FORM ONLY.




This two-page Signature Page will take care of several important policies and notices.


Please initial each item and sign below indicating that you received and read the following information as well as any attached pages. Keep the rest of the pages for your reference. This info is also in the Parent Handbook that will be available online after October 15 or by request. Call Cindy – 522-3310

*******************************************************************************************************************

As a parent of the above student, I understand that this information (except for Parent Participation) will be discussed fully in class at the beginning of the year, and it is our family’s responsibility to read and discuss it further.

Please initial all that apply.

Then BOTH Parent and Student sign on the last page.

Dance Agreement


____ (Initial) I received a copy of the Dance Agreement. I understand my student must be eligible to attend with passing grades and appropriate behavior. I or another adult must sign my student in and out at each dance. Students need to be picked up immediately at the end of the dance.

Cell Phone Policy – Initial choices

____My child does not have a cell phone.


____My child may have a cell phone in his/her possession. We have read and understand the Cell Phone Policy including information on Student Cell Phone Use and Consequences. We understand that possession of a cell phone by a student is a privilege. Phones will be taken to the office if they are on or seen during the school day and a parent will have to pick it up. The privilege will be forfeited by any student who does not abide by the terms of this policy. Please see the attached policy for more details.
Student Cell phone number____________________
Electronic Devices – Please initial

_____ My child and I have read and discussed the Electronic Device Policy and consequences for taking them to school. We understand that these are valuable personal property and are not allowed at school without express permission for a specific activity. Students and families assume all responsibility for such devices if they are brought to school.



Movie Permission – Please initial


POCS asks a lot from our middle school students. From time to time there is a movie related to the curriculum that we would like to show part of or in its entirety. Occasionally teachers show a movie as a reward for their hard work. Additionally we would like to show movies during recesses on rainy days for those students who are interested. Some movies we have shown in the past are: Shrek, The Princess Bride, Overboard, A Midsummer Night’s Dream, Ever After, Contact, Apollo 13, and Star Wars.
Please initial all that apply: My child_____________________________________(name)
___ has permission to watch PG movies ___DOES NOT HAVE permission to watch PG movies

___ has permission to watch PG13 movies ___DOES NOT HAVE permission to watch PG13 movies


OVER – TWO-SIDED - Be sure to complete both sides

PINER-OLIVET CHARTER SCHOOL Page 2

Signature Page: Dance Agreement, Cell Phone Policy, Electronic Devices, Movie Permission, Email Permission, Internet Use, Physical Education, and Community Service.

EMAIL- Please initial ___ I have email ____I do not have email


____The School and POCS Parent Club may use my email to contact me and send information.
Email address/ addresses:_________________________________________________

Please print clearly

Is there another parent that should be included? ____No ____Yes

Name___________________________ Email _____________________________________

Please print clearly

Technology Use Agreement


A signature at the end of this agreement is binding and indicates that the party who signs it has carefully read the attached Technology Use Agreement and understands the significance of the terms and conditions. No user has permission to use technology equipment and resources without this signed and dated form on file at the school.

Student: I (student) understand and will abide by the Technology Use Agreement as included in this packet. I further understand that any violation of the regulations above is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked and school disciplinary action and/or legal action may be taken.

Parent: I (parent) recognize that the Piner-Olivet Union School District and Piner-Olivet Charter School have taken reasonable precautions to set guidelines and monitor use and to limit opportunity to access harmful material or material that is not approved for use within the public school system. I also recognize it is impossible for Piner-Olivet Union School District and Piner-Olivet Charter School to monitor all use and restrict access to all harmful or unapproved materials and I will not hold the District or the School responsible for such materials encountered or acquired by my child on the network. I understand that this access is designed for educational purposes.
_____(Parent Initial) I (parent) give permission for my child to use technology including the Internet at Piner-Olivet Charter School under the provisions in the Technology Use Agreement. Further, I accept full responsibility for such materials acquired by my student and financial responsibility for any damages caused by him/her.
Physical Education – Please Initial

____(Parent Initial) I understand that my child has reviewed PE logs and grades with Mrs. Pinelli.

____(Parent Initial) My child and I have read and discussed Physical Education as outlined. We will contact Mrs. Drew-Ingham if we have any questions or concerns.
COMMUNITY SERVICE – Parent and Student Please Initial

____ (Parent Initial) My student and I have read and discussed the Community Service information.

____ (Student Initial) We understand that it is the family’s responsibility to make arrangements for my child to complete the hours and my student’s responsibility complete them responsibly and report them by turning in logs to the office. They are due 1 week before the end of each Trimester to be included in the Trimester report. They must be completed by the final due date (See calendar) for my child to participate in end of the year activities, and they are a requirement for promotion.

We have received the above information regarding Dance Agreement, Cell Phone Policy, Electronic Devices, Movie Permission, Email Permission, Internet Use, Physical Education, and Community Service. We understand it is our responsibility to read and discuss all of the above.

__________________________________________ ______________________________________

PARENT/ GUARDIAN NAME (PLEASE PRINT) Parent Signature
________________________________________ ______________________________________

Student Signature Date



Please complete both sides

Page 3

Student Handbook / Parent Handbook – Please initial

____ I understand that my student has received a Student Handbook and has gone over it in class with his/her teachers. I understand that the Parent Handbook will be available on the website and is available from the office.


If you want a Parent Handbook sent home with your student, please write a note below.

We have received the above information regarding Dance Agreement, Cell Phone Policy, Electronic Devices, Movie Permission, Email Permission, Internet Use, Physical Education, Community Service, and Handbooks. We understand it is our responsibility to read and discuss all of the above.


__________________________________________ ______________________________________

PARENT/ GUARDIAN NAME (PLEASE PRINT) Parent Signature
________________________________________ ______________________________________

Student Signature Date






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