DoDEA Consents and Authorizations Form 700

DEPARTMENT OF DEFENSE EDUCATION ACTIVITY STUDENT REGISTRATION
DoDEA FORM 700 – Consents and Authorizations
INSTRUCTIONS: 1. Completed by Sponsor/Parent or Guardian 2. Print (Ink) or type all entries.
3. One completed form is good for KN thru 8th grade; and/or one completed form is good for
9th thru 12th grade
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2164 and 20 U.S.C. 921-932; DoD Directive 1342.20, “Department of Defense Education Activity (DoDEA),” October 19, 2007
PRINCIPAL PURPOSE: To obtain consent and authorization needed to allow students to participate in school programs and activities and to disclose certain student information,
and acknowledgement of the emergency care that may be delivered to a student by DoDEA’s officials and health care providers. Information collected on this form is authorized by
the DoDEA system of records notice (SORN) number 26, published at http://dpclo.defense.gov/privacy/SORNs/component/osd/.
ROUTINE USE(S): In addition to the disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, this record or information may be disclosed outside the DoD as a
routine use pursuant to 5 U.S.C. 552a(b)(2-12), the DoD Blanket Routine Uses described at http://dpclo.defense.gov/privacy/SORNs/component/osd/ and the DoDEA routine uses
found in SORN 26.
DISCLOSURE: Granting the consent and authorization requested by this form is voluntary. However, the failure to complete the form and provide the requested
consent/authorization/acknowledgement of notice, may delay or prevent the DoDEA student’s enrollment or participation in activities requiring consent or authorization.
Student Last Name
Student First Name
Student ID (School Use Only)
SECTION I – AUTHORIZATION DESIGNATIONS FOR STUDENTS ENROLLED IN DODEA SCHOOLS
(Applicable only to the dependent student registering with this form)
1. Authorization to Attend Study Trips (i.e., one-day, no overnight DoDEA-funded trips): The undersigned authorizes my student to
participate in authorized DoDEA school study trips as initialed below: (Mark the appropriate box)
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All authorized study trips
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Individual: I request that the school obtain my permission
in advance of each study trip involving my student.
2. Authorization to Disclose Directory Information to Various Media: The undersigned authorizes DoDEA to disclose my student’s media
directory information (student name, and/or ID, school, grade level, student e-mail address, image, major field of study, participation in
officially recognized activities and sports, weight and height if student is a member of a school athletic team, dates of attendance, degrees
and awards received, the most recent previous educational agency or institution attended by the student, and/or student work products) to
DoD and public news media, DoD-sponsored print and/or electronic media, including, for example, DoD news networks, student
newspapers, yearbooks, and similar student’s school publications; DoD or DoDEA-sponsored or approved websites or web services
(including social media); DoD or DoDEA brochures, booklets, and video/audio productions. (Mark the appropriate box)
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Authorize
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Decline to authorize
Yearbook Only
3. Authorization to Disclose School Records to Other Schools: The undersigned authorizes DoDEA to release a copy of my student’s
official school records to another school to which my student is transferring or has transferred, upon written request from the gaining school,
without notifying or providing the undersigned with a copy of the released school records. The undersigned understands that I may opt out
of this authorization at any time by furnishing a written notice of my decision to the school principal, subsequent to which the school will
not release my student’s records to another school without prior written consent.
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Decline to authorize
4. Authorization to Disclose Student Directory Information to Military Recruiters: The undersigned authorizes DoDEA to disclose to U.S.
Military recruiters the following recruiter directory information pertaining to my student: age 17 and older or enrolled in the 11th or 12th
grade: name, address, and telephone number.
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Decline to authorize
5. Authorization to Participate in Authorized Survey: The undersigned authorizes my student to participate in any survey authorized by
DoDEA Headquarters, except that either I or my student may decline to participate in (opt out of) any particular survey. I understand that
DoDEA authorizes surveys only after a committee of DoDEA educators has determined that the survey will produce high quality data of use
to DoDEA that is not generally available through another means, in accordance with the criteria and rules of DoD Instruction 1100.13,
"Surveys of DoD Personnel." Authorized surveys will collect data anonymously. Authorized surveys will not collect data about my
student's or my family's health, medical status, mental or psychological condition, or personality. Authorized surveys will explore students’
experience with and opinions about DoDEA school programs, participation in the use of various learning technology and equipment, future
career or education plans, and satisfaction with or achievement in learning. In the event that a survey falls outside of these parameters,
DoDEA will seek additional specific parental consent.
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Decline to authorize
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STUDENT NAME __________________________________________
6. Authorization to Obtain Post Graduate Student Data: The undersigned authorizes DoDEA to obtain information on my student’s
postsecondary college enrollment. The information gathered from this data will be used to refine the academic programs and the
college/career readiness of my student in order to improve postsecondary success.
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Decline to authorize
7. Authorization to Disclose Electronic Directory Information: The undersigned authorizes DoDEA to disclose basic electronic directory
information (student name, student ID, school, grade level, and student email address) to providers of DoDEA and other DoDEA approved
web-based educational programs, and to providers of other voluntary educational services or programs, such as voluntary testing services.
This disclosure is critical to student participation in optional programs, such as access to electronic educational software, certain educational
testing, student email, and school food services.
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Decline to authorize
SECTION II - SPONSOR/PARENT/GUARDIAN ACKNOWLEDGEMENTS
1. Disclosure of Student Information by Emails to Sponsor/Parent/Guardian: The undersigned acknowledges that DoDEA may
communicate information about my student in official email communication to me and/or my student. The undersigned understands that
DoDEA staff exercise care to limit the inclusion of personal student information in such emails, but it cannot guarantee that such
communication will not always avoid the inclusion of my student’s personalized information, such as about the student’s health, discipline,
or other student educational information. The undersigned further understands that if I object to the use of email communication concerning
my student, that I must inform the principal in writing of my desire to receive such communication by alternate means.
2. Use of DoDEA Internet and Use of Information Technology Resources: The undersigned acknowledges that my student’s use of
DoDEA Information Technology resources is contingent upon agreement and compliance with the “Appropriate Use of DoDEA
Information Technology Resources – Terms and Conditions for DoDEA Students” (hereafter “Terms and Conditions”) and can be found at
http://www.dodea.edu/Offices/Regulations/loader.cfm?csModule=security/getfile&pageid=93099. The DoDEA requires parental/guardian
signature for students in grades PK-3 and student signature for grades 4-12. If my student violates the Terms and Conditions, the
undersigned understands that my student may be subject to school disciplinary and/or appropriate legal actions and may lose all access to
DoDEA technology resources (which include the privileges of access to DoDEA communications and computer equipment, related
software, and services, such as e-mail and Internet access, educational programs and services, and social media). The undersigned
understands that the school will exercise reasonable care to prevent my student from accessing undesirable information on the Internet;
however, the undersigned is aware that the school may not be able to prevent my student from accessing all such information or on-line
communications. By completing DoDEA Form 700A, Internet Agreement and Consent to Use Information Technology Resources, and
signing Section IV of this form, the undersigned certifies that he/she has read, understands, and agrees to abide by the Terms and Conditions
and to ensure that my child also understands and agrees. The undersigned hereby consents to my student’s use of DoDEA’s Information
Technology resources, in accordance with DoDEA Terms and Conditions.
3. Acknowledgement of Financial Responsibility for Property and Equipment that is Lost, Damaged, Destroyed or Stolen and for Duty to
Pay for School Meals: In accordance with the policy of DoD Instruction 5000.64, Accountability and Management of DoD Equipment and
Other Accountable Property, as amended, and the basic obligations of public service described in the Standards of Ethical Conduct for the
Executive Branch, 5 CFR 2635.101, I acknowledge that I am financially liable for Government-owned or leased property and equipment
that is lost, damaged, destroyed, or stolen while that equipment is in my use, custody, or control, or the use, custody, or control of one of my
family members. In addition, I am financially obligated to pay the cost of any school meal that is provided to me or to my child. I
understand that my financial liability includes the costs, such as attorney fees, interests, and other collections costs, incurred by the
Government to collect amounts that I owe the Government. I further understand that the term lost, damaged, destroyed, or stolen, refers to
circumstances arising from neglect by me or my family member, and does not apply to circumstances that are beyond my or my family’s
ordinary care that cause depreciation of value due to ordinary wear and tear. The term “property or equipment” includes school furnishings
(such as desks, chairs, classroom supplies and equipment, textbooks, laboratory equipment and supplies, electronic equipment, seats and
furnishings on school-provided or funded busses and other school-provided or funded transportation conveyances). I understand that school
authorities will notify me when it asserts a claim against me, that I will be given the opportunity to see all evidence supporting the school’s
assertion of my liability, that I will be afforded the opportunity to present argument and evidence challenging my liability to appropriate
authority as prescribed in DoDEA rules and regulations, and that upon a preliminary determination by school authorities of my liability, I
can appeal that decision to appropriate authority as specified in DoDEA rules and regulations. However, once I have exhausted my rights
under DoDEA regulations, without eliminating the determination of my financial liability, I acknowledge my duty to promptly make
payment in full of the amounts due in accordance with DoDEA rules concerning payment. I acknowledge that my failure to make prompt
payments may result in the denial of access by me or my family member to school-provided resources, such as computers and electronic
equipment, software or textbooks, or school meals, that the school may decline to photocopy my student’s academic records or transcripts,
and that the fact of my nonpayment may be reported to my command.
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STUDENT NAME __________________________________________
SECTION III – EMERGENCY HEALTH CARE NOTICE AND ACKNOWLEDGEMENT
DoDEA will assist a student in the event he or she becomes ill or is injured while engaged in school sponsored activities, including
athletic and academic competitions and study trips. The school will follow the procedures identified below, from the administration of
first aid through referral to health care providers for necessary treatment. The health care/medical provider may not always be a U.S.
licensed medical doctor (physician).
1.
2.
3.
4.
5.
6.
7.
8.
School to Administer First Aid: School personnel will administer first aid to my student when needed to treat minor injury or illness.
Emergency Contact, Emergency Response and Transportation for Emergency Care: Should the student sustain an illness or injury
that a school official believes should receive immediate care from a health care provider, the undersigned understands that the school,
a) will make reasonable efforts to contact the undersigned, or the alternate individual(s) identified as emergency contacts on my
student’s registration document (DoDEA Form 600), and, if necessary,
b) will arrange for a response by an Emergency Response Team (EMT) and possible transportation of my student for treatment to an
available health care facility. The (EMT), health care facility, or attending health care provider(s) may not be U.S. or military
facilities or providers, especially if my student is located overseas.
Treatment Decisions to be Made Exclusively by Health Care Provider(s): If the nature of my student’s injury or illness requires
immediate health care, then attending health care providers will make decisions, in accordance with their standard operating
procedures, regarding the delivery of emergency care for my student.
Cost of EMT/Transportation/Health Care: DoDEA shall not be responsible for the costs of any EMT or transportation of my student to
a health care provider, or for the cost of care provided to my student by the health care provider(s).
School Does Not Administer Medication or Food Without a Physician’s Order: The school does not administer medicine or daily food,
snacks or drinks to my student as a part of his/her physician-prescribed treatment program, unless the undersigned has provided the
school with medications and/or food along with a physician’s order giving instructions on the administration of the medicine and/or
food.
Duty to Inform the School: It is the personal responsibility of the undersigned to inform the school of changes in my student’s health
status or emergency contact information. The undersigned agrees to notify the school principal in writing of any such changes.
Release of Student Information The school will release information in its possession that is pertinent to my student’s health
condition(s), including any health and emergency contact information to my student’s sponsor/parent/guardian, health care provider(s),
police officials, and others who need to know information in order to render health care to my student, or to protect the safety of any
person or property.
Effect of Failure to Sign this Notice and Acknowledgement: The failure to sign this Notice and Acknowledgement may delay
or prevent my DoDEA student’s participation in activities requiring authorization.
SECTION IV - SIGNATURE BLOCK
By my signature below, I (and my student age 18 or over) acknowledge that I have read and fully understand the information
contained in each section I-III of this DoDEA Form 700 (including documents referenced within this form). Further, my signature
acknowledges that I provided or declined to provide the authorizations, as indicated, in paragraphs 1-7 of section I and 1-3 of
section II, and that I, understand that these authorizations and acknowledgements shall remain operative until the form is updated
by the undersigned.
Signature of Sponsor/Parent/Guardian_________________________________________________
Printed Name:________________________________________ DATE:______________________
Signature of Student Age 18 or older:__________________________________________________
Printed Name:________________________________________ DATE:______________________
DoDEA Form 700, December 2014
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