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JH & HS Website Enrollment Form

Enrollment Form:

Enrollment



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Student Information:

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Contact Information:

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Additional Emergency Contact Names and Numbers

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eNote Notification System







Special Conditions

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Corporal Punishment


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Home Language Survey

If the following responses are something other than English, additional paperwork will be required.




Internet & Wireless Telecommunications Devices

Terms and conditions of Cement Public Schools Internet and Wireless Telecommunications Devices can be accessed on the school website and the student handbook.





Drug Testing Policy

Terms and conditions of Cement Public Schools Drug Testing Policy can be accessed on the school website and the student handbook




Student Transportation


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Emergency Medical Treatment Consent




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Authorization to Share Protected Health Information

I understand that by voluntarily approving this authorization: 1) I authorize the use or disclosure of my Physical Health Information as above for the purposes listed, 2) I have the right to withdraw permission for the release of my information and revoke this authorization at any time in writing, 3) I have the right to receive a copy of this authorization, 4) I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment, or payment of claims, 5) I understand I may change this authorization at any time in writing, however, I understand I cannot restrict information that may have already been shared based on this authorization, and 6) information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA Privacy Regulations.

Authorization

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Required Fields