2017-2018 SCHOOL YEAR ANNUAL NOTICES

Dear Parent/Guardian:
EMERGENCY MEDICAL AUTHORIZATION
State law requires all Ohio public schools to offer parents or guardians the opportunity to complete an Emergency Medical Authorization form
on each of their children in the public schools for emergency hospital treatment for illness or injury, in cases where the parent or guardian
cannot be contacted for approval of such emergency treatment.

Please complete Part I of the Emergency Medical Authorization form for each of your children if you would like this information on file at
the schools. Complete part II if you do not want emergency treatment permission on file.
SECTION 3313.712, OHIO REVISED CODE
Annually the board of education of each city, exempted village, local and joint vocational school district shall, before the first day of October,
provide to the parent of every pupil enrolled in schools under the board's jurisdiction, an emergency medical authorization form that is an
identical copy of the form contained in division (B) of this section. Thereafter, the board shall, within thirty days after the entry of any pupil
into a public school in this state for the first time, provide his parent, either as part of any registration form which is in use in the district, or as
a separate form, an identical copy of the form contained in division (B) of this section. When the form is returned to the school with Part I or
Part II completed, the school shall keep the form on file, and shall send the form to any school of a city, exempted village, local or joint
vocational school district to which the pupil is transferred. Upon request of his parent, authorities of the school in which the pupil is enrolled
may permit the parent to make changes in a previously filed form, or to file a new form.
If a parent does not wish to give such written permission, he shall indicate in the proper place on the form the procedure he wishes school
authorities to follow in the event of a medical emergency involving his child.
Even if a parent gives written consent for emergency medical treatment, when a pupil becomes ill or is injured and requires emergency
medical treatment while under school authority, or while engaged in an extra-curricular activity authorized by the appropriate school
authorities, the authorities of his school shall make reasonable attempts to contact the parent before treatment is given. The school shall
present the pupil's emergency medical authorization form or copy thereof to the hospital or practitioner rendering treatment.
Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts to comply
with this section.
Please return one green form for each child to the school to which he/she is assigned by TUESDAY, SEPTEMBER 5, 2017.
STUDENT DIRECTORY INFORMATION
In compliance with Federal regulations and Board Policy 8330, the Oberlin City School District has established the following guidelines
concerning student records.
The Building Principal is the Custodian of Records and is responsible for the supervision of all student records. Student records are
maintained in the school building office. You may reach the building principal by telephoning:
Eastwood Elementary School Office 776-4502 Prospect Elementary School Office 776-4503
Langston Middle School Office 776-4504 Oberlin High School Office 776-4501
Each student’s records will be kept in a confidential file located at the student’s school office. The information in a student’s record file will be
available for review only by the parent or legal guardian of a student, adult students (18 years of age or older), and those authorized by
Federal law and District regulations.
A parent, guardian, or adult student has the following rights:

1. inspect and review the student’s education records

2. request amendments if the parent believes the record is inaccurate, misleading, or otherwise in violation of the student’s rights
3. consent to disclosures of personally-identifiable information contained in the student’s education records, except to those
disclosures allowed by the law
4. challenge District noncompliance with a parent’s request to amend the records through a hearing
5. file a complaint with the Department of Education
6. obtain a copy of the District’s policy and administrative guidelines on student records
Each year the district will provide public notice to students and their parents of its intent to make available, upon request, certain information
known as “directory information”. This letter serves as such notice.
The district, in compliance with Ohio Revised Code, has established the following information about each student as “directory information”:
student’s name; address; date and place of birth; major field of study; participation in officially-recognized activities and sports; height and
weight, if a member of an athletic team; dates of attendance; date of graduation; awards received; honor rolls; and scholarships.
State law provides that “directory information” may be released by a legitimate request (i.e. non-profit organizations, military recruiters,
colleges & universities). The Federal “No Child Left Behind Act” requires us to release “directory information” to military recruiters unless a
parent/guardian (or student 18 or older) specifically denies this information from release. YOUR DECISION NOT TO RETURN THE BLUE
FORM BY TUESDAY, SEPTEMBER 5, 2017. WILL BE TAKEN AS INSTRUCTION TO OBERLIN CITY SCHOOL DISTRICT NOT TO
RELEASE THE REQUESTED INFORMATION AND YOUR CHILD’S NAME AND CONTACT INFORMATION WILL NOT BE RELEASED.
Sincerely,

Dr. David H. Hall

Superintendent

Cut here ------------------------------------------------------------------------------------------------------------------

Please complete this section, sign and return along with the enclosed forms no later than September 5, 2017

Print Student Name School Parent Signature

PARENT CONSENT FOR RELEASE OF STUDENT NAME AND/OR PHOTOGRAPH FOR PRINT/MEDIA
I give permission to use my son’s or daughter’s name or photograph in class or school projects created for print or electronic media (internet)
or on the school district website (http://www.oberlin.k12.oh.us) recognizing that at no time will the child be identified directly with both their full
name and their photograph. When my child’s name or photograph is included in material prepared for the internet the student and the parent
will be given the internet address of such material.
I authorize OCSD to release I DO NOT authorize OCSD to release

INTERNET ACCEPTABLE USE POLICY

As the parent/guardian of this student, I have received, read and understand the Acceptable Use Policy for Internet Access for the Oberlin
City SD. I understand that Internet access at school is provided for educational purposes only. I understand that employees of the school
system will make every reasonable effort to restrict access to all controversial material on the Internet, but I will not hold them responsible for
materials my son/daughter acquires or sees as a result of the use of the Internet from school facilities, should objectionable pictures or
information appear by accident the district will take immediate action to correct that situation.
I give my permission I DO NOT give my permission

STUDENT DIRECTORY INFORMATION

Our school may be requested to provide the names and addresses of students to military recruiters, colleges and other groups. You do
not have to participate in this program. Please check below to indicate whether you wish to have your child’s name, address and
telephone number disclosed to the groups that may request it. – PLEASE CHECK ONE:
I AUTHORIZE Oberlin City Schools to disclose my child’s name, address and phone number as a part of the school directory
DO NOT DISCLOSE my child’s contact information without my prior permission
DO NOT DISCLOSE my child’s name, address and telephone number to the entities checked below without my prior permission:
US Military (Army, Navy, Air Force, Marines, etc.)
Colleges and other educational institutes
Prospective employers

YOUR DECISION NOT TO RETURN THIS SECTION WILL BE TAKEN AS INSTRUCTION TO OBERLIN CITY SCHOOL DISTRICT NOT TO
RELEASE THE REQUESTED INFORMATION AND YOUR CHILD’S NAME AND CONTACT INFORMATION WILL NOT BE RELEASED.
 EMERGENCY MEDICAL AUTHORIZATION & FIELD TRIP CONSENT 2017-2018

Student Name School Building

Student Address Primary Emergency Contact Telephone Number

Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children
who become ill or injured while under school authority, when parents or guardians cannot be reached.

Residential Parent/Guardian

Mother’s Name Daytime Phone

Evening Phone Cellular Phone
Father’s Name Daytime Phone
Evening Phone Cellular Phone
Other’s Name Daytime Phone
Evening Phone Cellular Phone
Name of Relative or Childcare Provider
Address
Relationship Daytime Phone
Evening Phone Cellular Phone

PART I OR II MUST BE COMPLETED AND RETURNED TO THE SCHOOL OF ATTENDANCE

PART I - TO GRANT CONSENT

I hereby give consent for the following medical care providers and local hospital to be called:
Physician Phone
Dentist Phone
Medical Specialist Phone
Local Hospital ER Phone
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the
administration of any treatment deemed necessary by above-named physician/dentist, or, in the event the
designated preferred practitioner is not available, by another licensed physician/dentist; and (2) the transfer of
the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two (2) other licensed
physicians/dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such
surgery.

Facts concerning the child's medical history including allergies, medications being taken, and any physical
impairments to which a physician should be alerted:

(OVER)
I authorize the above named student to go on school-sponsored field trips during the current school year. I
understand that this includes all school-sponsored field trips both on foot and also by bus.

It is understood and agreed that the Oberlin City Schools and the teacher/administrator/coach in charge shall
exercise reasonable care and precautions to make these trips as safe as possible. Responsibility beyond this
cannot be assumed by the employee or the school.

Specific information regarding field trips will be sent home prior to the individual field trip.

EMERGENCY MEDICAL AUTHORIZATION & FIELD TRIP APPROVAL

Date Signature of Parent/Guardian

DO NOT COMPLETE PART II (BELOW) IF PART I (ABOVE) COMPLETED

PART II – REFUSAL TO CONSENT

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury
requiring emergency treatment, I wish the school authorities to take the following action:

Date Signature of Parent/Guardian

R.C. 3313.712

PART III – SUPPLEMENTAL INFORMATION (OPTIONAL)

Student’s Birthdate Grade Teacher/Homeroom

Date of Last Tetanus

Student resides with (circle all that apply) Mother Father Step-Parent Guardian Other

Additional Contact Information for those who have authority to make decisions in an emergency situation
involving this student.

Step-parent Home # Work # Mobile #

Guardian Home # Work # Mobile #

Alternate Home # Work # Mobile #

(relative/child care provider)

Green
Revised 09/2016