CSN Education Department - Field Observation Activities Packet

Greetings Future Educator,

One of the most rewarding aspects of EDU 201, EDU 202, and EDU 203 is the opportunity you’ll have to
observe in a school classroom where students are actively engaged in learning. Each of these three CSN courses
requires all students to complete a 10 hour "Field Observation" in a Clark County public school.

Once your placement is processed, you will receive details regarding your assigned school from your
CSN professor. Only then, will you contact the school and meet with your CCSD “cooperating teacher”. Both you
and your cooperating teacher will design a mutually agreeable schedule to complete your required contact hours
once you meet for the first time.

Within this packet, you will find the required field experience assignments and other documents that you
must complete in order to pass this class.

Your Name: >>> Alexus Cornejo

CSN Course: >>> Introduction to Special education 203-2002

Professor: >>> Jacqueline Sgobba

Professor’s email: >>> jacqueline.sgobba@csn.edu

CCSD School: >>> Mark L. Fine Elementary School

Cooperating Teacher: >>> Lauren Desander

Save this completed packet for this class, and your Education Capstone Course, (EDU 299). Your CSN instructor
will let you know their required format for submitting the observation assignments within this packet.

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BEFORE ARRIVING ON THE FIRST DAY...

1. Locate your assigned school on a map, or via the CCSD website, and arrive during the Initial Visitation Week
dates provided to you by your CSN instructor. This initial visit will be your chance to gather information about your
assigned cooperating CCSD teacher. School locations and other information can be found on the CCSD web site
at http://ccsd.net/schools/contact-information/

2. Pre-plan for an on-time arrival, and make sure that all interaction with CCSD employees and students is
respectful, courteous, and professional. You are a guest in their school, and a representative of this class and the
college. CCSD is allowing you to visit their school to further your understanding of the teaching profession. It is
imperative that your actions reflect a willingness to learn, and are reflective of a future professional educator.

3. The first half of your field observation/experience will be centered around learning about the school you were
assigned, and focusing on the general and unique characteristics of its culture. You will be looking at and
reflecting upon things that are going on in the classroom at the school level that you were assigned. You are
simply observing during this time. Your cooperating teacher will give you guidance on how your experience can
be expanded beyond simple observations, when he/she feels comfortable with your professionalism and skills.

UPON ARRIVAL THE FIRST DAY…

Check in at the school office and let the Office Manager know that you are a CSN Education student who has
been placed with a cooperating teacher at their school for Field Observation as well as fill out ANY check-in
paperwork for school safety. Be patient while the information you’ll need is located by the Office Manager. The
request for placement came through Gmail from our Field Observation Coordinator (Corinne Blake), and has
been pre-approved by the school’s administrator. During this initial visit, some of you may be sent directly to the
classroom to meet your cooperating teacher, some of you may be given contact information for the cooperating
teacher, and then will return on a different day for your first classroom visit.

UPON ARRIVAL TO THE CLASSROOM…

Introduce yourself to your assigned Cooperating Teacher. Since this is your first visit, ask the teacher where
he/she would like you to sit while you complete your observation hours for this CSN Introduction to Education
class. Show the teacher this “Field Observation Activities Packet”, as well as the last 3 pages which contain the
“Cooperating Teacher Information”, the “Time Log” and “Field Observation Student Evaluation” pages.
Let the teacher know that you will be taking notes during the observation for your packet assignments, and that
you will be asking him/her to verify your hours of attendance, and evaluate your participation once the total
observation hours are complete.

DEPARTMENT OF TEACHER EDUCATION FIELD EXPERIENCE GUIDELINES

Standards of Conduct
You are student representatives of the CSN Education Department and the teaching profession. Candidates are
expected to maintain high standards of personal and professional ethics.

CCSD COVID Procedures

Students must abide by all CCSD policies regarding the safety of staff and students. For up-to-date information
please visit: https://ccsd.net/departments/risk-management/covid-19-information

Attendance and Punctuality

Regular attendance and punctuality are mandatory. Once you plan a schedule with the
cooperating teacher, this becomes an agreement in which you are expected to adhere to. You are expected to
sign in and out at the school (as required by the school office and/or program). In case of illness or emergency,
you must contact the assigned school and let them know you will not be in attendance on that day so they can
notify your cooperating teacher.

Relationships
You should exercise respectful discretion when voicing your personal views. It is important that your demeanor
and opinions remain confidential. Under no circumstances can information about any students be released to, or
discussed with, any unauthorized person. It is forbidden to have any contact with students outside of the
classroom you are assigned. This restriction also includes CSN students contacting CCSD students using any
electronic means or through the use of social media.
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Dress Code
CSN Department of Education wants you to be a success. Therefore we have established a dress code for
students fulfilling their observation requirement in the assigned school district. Appearance creates credibility;
make a good first impression by dressing professionally.

Required Acceptable Attire:

Males:
• Shirts with collars
• Ties (optional) with button down shirts
• Khakis, trousers, slacks; belts if pants have loops, (no sagging, rips or tears)
• Simple jewelry
• Shoes and socks that cover the toes and heels

Females:
• Shirts or blouses that cover the shoulders & waist; no see-through or mesh
• Sweaters worn over shirt
• Pants, pantsuits, khakis, trousers, slacks (no sagging, rips or tears)
• Jumpers, dresses, skirts (in length from 2" above the knee to the ankle)
• Shoes and socks that cover the toes and heels
• Leggings worn under dresses/skirts/jumpers
• Simple jewelry or none
• Little (daytime) make-up

Not Acceptable Attire: jeans, shorts, tank tops, halter tops, muscle T-shirts, tight fitting clothing, warm-ups,
sandals, flip flops, stilettos; no cleavage showing, no sagging or frayed hems; no head covering except for
religious reasons, such as a yarmulke or turban-like. No nontraditional hair colors/styles. Undergarments and
tattoos should be covered. Remove facial jewelry. No perfume. *School principal/supervisor has the sole
discretion on questionable clothing or appearance that distracts from student learning.

Classroom Conduct:
At all times, the cooperating teacher maintains legal responsibility for pupils in his or her classroom. You should
never assume that responsibility and be left unsupervised with children. You should not discipline students. You
are an observer, who should take notes to discuss during your next education class meeting, or to record in your
Field Observation packet.

Professional Conduct:
Never speak to staff or students in an abusive manner.
Never touch or be alone with a student for any reason.
Never give a student food, drink, or other items without the teacher’s permission.
Never take photos/video of students or staff without written permission from the principal.
Never make or accept calls/text using any communication device.

REVIEW THE TERMS of the CCSD Waiver Forms you agreed to:
“Student Statement of Responsibility” (Exhibit B)
“Student Confidentiality Statement” (Exhibit C)

These 2 waiver documents MUST be agreed to during the Field Observation registration process in order to
secure your placement. Completion of the Field Observation is a PASS/FAIL component of the course.

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ASSIGNMENT 1 (Observations): After arrival, take a seat in a nonintrusive location to begin your classroom
observations. Complete the questions below:

Observation 1: What are your first impressions of the classroom environment? Is it warm, inviting, organized,
etc? Describe the physical environment in detail. >>>
Upon first arrival the class was very organized and got to doing their work right away. The class
seemed very warm and welcoming. All the students seemed to be friends with one another and got
along well. The room was set up with a lot of space to move around.

Observation 2: Please describe the student make-up of the class, including gender, ethnicity, ELL, students with
physical challenges, and any other apparent attributes that are important to note. >>>
The class is very diverse when it comes to the student make-up. There is almost an even
number of girls and boys in the class. Each table has two boys and two girls except for one table that
had two girls and one boy. On the first day I visited the classroom there were six absences. The class
had a majority of White and Asian students with a few Black and Hispanic students. There were no
students in ELL or with physical challenges.

Observation 3: What are the posted class rules in the room? (exactly as written) >>>
The rules in the classroom were written to be respectful and kind to others, come prepared to
learn, follow directions quickly, listen to others, and do your best.

Observation 4: Does the teacher enforce these posted rules? Are rewards or consequences being used for
compliance or noncompliance? >>>
The teacher did enforce these posted rules. The students were to speak to each other in a
respectful manner and not to talk over each other. At the school the teachers are not allowed to punish
students so the teacher can only tell the students to stop talking or to calm down.
ASSIGNMENT 2 (Classroom Layout): Use graph paper or drawing software to create an accurate overhead
view, labeled drawing, of your assigned classroom before answering the questions below

Classroom Layout Question 1: Describe the workflow of the room. Is space used efficiently? >>>
There is enough space for students to make their way around the classroom. It seems to be a
pretty efficient use of the space. It is not a very large classroom, but everything is placed so it doesn’t
look clustered.

Classroom Layout Question 2: In your opinion, how can the physical arrangement of the room be improved?
>>>

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 The only improved physical arrangement I could see was implementing chairs that are on
wheels and have the desk attached to them. These seem to be the most space saving option for this
classroom.

ASSIGNMENT 3 (Instruction): Observe any instructional time in your assigned classroom, and record your
observations when presented with the questions below:

Instruction Question 1: What is the posted daily schedule for different subjects or periods? >>>
The schedule the class follows is:
9:10-9:20 Class Meeting
9:20-9:40 Social Studies/Science/Health
9:40-10:50 Math
10:50-11:15 WIN
11:15-11:25 Recess
11:25-11:55 Lunch
11:55-12:05 Recess
12:05-1:35 Reading
1:35-2:25 Specials
2:25-3:21 Writing

Instruction Question 2: Is instruction done in small groups, centers, whole groups, individual? >>>
A majority of the assignments I saw were done in partners or individually. Students were asked
to look up a reading about goods and services on one of the days I went, and they did it in pairs and
were asked to create a chart to compare the two. There were a couple of times when students were
asked to have a table discussion about what answers they got. Most of the time students would work
on their chrome books on their own assignments.

Instruction Question 3: How would you describe your cooperating teacher’s teaching style? >>>
The teacher has a very hands-on approach to teaching. The teacher took the time to have a
reading table at the back and would call back students to learn different things. For some of her groups
she took time to teach them new sounds and other groups would have readings they would have to
discuss. It seems to be very helpful for the students to have these groups and the teacher is not afraid
to correct and help the students.

Instruction Question 4: Does the teacher incorporate the sensory modalities (learning styles)? If so, give
examples. >>>
There were a lot of kinesthetic assignments in the classroom. For example, towards Christmas
the students-built Christmas trees out of pipe cleaners. There were also counters in the classroom for
the students to have a visual representation of the numbers. There were many assignments where they
could get out of their seats on, I saw them going around the room playing beat the calculator.

Instruction Question 5: Do the students seem engaged in the lesson(s) that are being presented? Please
explain. >>>
The students are engaged in every lesson presented. The teacher makes sure to have the
students interact by having them answer questions. The students also raised their hands when asked
to participate and were even excited to answer. The students were not scared to share any method

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they used or their thoughts on a subject. The students weren't scared to get answers incorrect and they
kept trying.

Instruction Question 6: Are there any students isolated from the rest of the class for any reason? Why? >>>
There were no students in the classroom that were isolated. All the students were in at
least a group of two and most of the time all the tables were full.

Instruction Question 7: Is instructional time managed efficiently? Please explain >>>

The instructional time was managed extremely efficiently. There was a set amount of time for
every subject and the teacher always made sure to finish on time and immediately move on to the next
subject.

Instruction Question 8: How does the cooperating teacher handle transitions from one subject or period to
another, and are these transitions efficient? >>>
The way the teacher moves from subject to subject is by having the students put away all the
material from the previous subject then announces they will be moving on and has them pull out
materials for the next subject. This was extremely effective and worked every time.

Instruction Question 9: List ways that the teacher attempts any “attention getting” commands? (Ex: Countdown,
Light flicker, Heads on Desk) How effective are they? >>>
The teacher either calls the students by their names or if it is the whole class the teacher says
class class and the students respond with yes yes. Also, the teacher will do a countdown to get the
students' attention. These were very effective in getting the students' attention.

Instruction Question 10: What specific behavior issues does the teacher have to deal with? How does the
teacher deal with these behavior issues? Be specific. >>>
The material being provided by the teacher had marks and stabs in it. The teacher asked the
students to treat the materials better and to not destroy the new material. I think she handled it well by
announcing the issue and saying what to do to avoid it.

Instruction Question 11: Are there any policies or procedures in place that help or hinder instructional time? If
so, explain them and how they help or hinder use of instructional time. >>>
One procedure set in place to help instructional time is the teacher will countdown from 5 to
make sure students are doing what they are supposed to be doing. She also praises the students that
get to work on time to encourage the rest to do the same. This is a very effective procedure.
ASSIGNMENT 4 (Culture): Using the information provided below, carefully observe and evaluate the culture of
the school where you are assigned to observe. Remember you are evaluating the school for its educational
culture, place of learning, sense of safety, invitation for learning, promotion of self-actualization, development of
values and socialization.

Physical Characteristics: Look at the physical areas of the school to determine atmosphere, comfort, and
feelings the school creates for students in the educational setting.

1. Consider the school property: building, grounds, fencing, equipment, landscaping, trees, parking lot,
crosswalks, gates, signs and symbols. >>>
The building is very big. There are two large fields, one located in the front for Pre- K
students and one in the back for the older students recess and P. E class. The classrooms are
all indoors and it is an enclosed school surrounded by fences. There are many signs and
symbols to indicate there is a school. There are also two crosswalks.

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 2. Next, study the interior of the school: halls, floor coverings, lighting, doors, windows, hall colors and
decorations and entrance security. >>>
The halls are very wide, leaving enough room for two classes to pass with no problem.
The lighting in the room is standard with wide rectangles on alternating celling spaces. There
are no windows in the classroom. The classrooms are painted white with a yellow trim across
the top portion of the room.

Culture of the School: Read, listen and observe to determine the climate, values, and atmosphere within the
school.

1. Identify the school’s mission statement, motto, and mascot. >>>

The school’s mission statement is “Mark Fine Elementary School lays the foundation for
social and academic growth, develops personal responsibility and designs positive goals for the
success of our students and their future.” The school's motto is “We are a community of FINE
citizens igniting a successful mindset for learning and inspiring FINE citizens to achieve their
personal best every day, in every way.” The mascot is a Fire bird.

2. Analyze staff and visitor interactions in the main office. Note student and faculty interactions in other
areas of the school. >>>
All the staff in the main office were very kind and helpful. Every teacher in the hallway
would greet me. The students are well behaved and punctual. The teachers would help students
that looked lost in the hallway and make sure they were getting where they needed to be.

3. Look at the formal practices: School bell schedule, and the grouping of students. (ie. grades, block
scheduling, periods) Does the school use inclusion, or a pull-out program for special education students?
>>>
The school follows a bell schedule that indicates when to be in class, when the lunches
were, and when it was time to leave. The students are grouped by grades. There were two
students that would get pulled out of the class to go with another teacher for reading.

4. Observe student-to-student interactions, inside and outside of the building. Observe where students
gather to socialize – lunchroom, halls, playground, etc. >>>
The students are all very friendly with one another. In the building the students would
interact with students at their table outside and many seemed to have friends in other classes
too. They mainly seemed to interact in the lunchroom.

5. Examine school traditions, achievements and awards; community recognition or community partners;
extracurricular activities/clubs and athletics. Look for and document sources of community pride and
sense of identity through ceremonies, assemblies, trophies, and artifacts. >>>
On the school's website they have traditions such as having a spirit week. They also
have award assemblies held for the student accomplishments. They don’t have any athletics or
clubs. They offer before and after school care programs. In the hallways there is a case with
many trophies.

Culture of the Classroom: Each classroom has its own culture and way of life.

1. Look for teacher(s) expectations for learning and success, interactions with students, and his/her
personality. >>>
The teacher expects the students to be actively participating in the classroom. I believe
she wants to see every student do well. She is very friendly and familiar with her students. She
is caring but also strict when needed. She can be serious at times and is not afraid to correct
her students but is also very understanding.

2. Evaluate the level of student participation in the class. Who participates? Who does not? What
modifications, accommodations, and/or inclusion techniques were observed? >>>

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 Every student participated at least once in the class. Alle the students were raising their
hand to share or give answers. There were a couple of students that had quiet voices so the
teacher suggested speaking up to make sure everyone could hear. There was only one time I
saw her call on a shy student because she saw she had the correct answer.

3. Evaluate the interactions between teachers and students, rapport, cohesiveness, distribution of power,
tone, frequency and reinforcements. >>>
The teacher and students seem to have a close relationship. The teacher and students
talk to each other in the same tone and frequency. I heard a lot of positive reinforcement. The
teacher gave shoutouts to students that improved in their math or reading. If the class got a little
loud the teacher would redirect their attention.

ASSIGNMENT 5 (Cooperating Teacher Interview): Complete the questions below by interviewing your
cooperating teacher during a convenient time. Include any school documents that your cooperating teacher will
allow you to photocopy for your packet.

Interview Question 1: What was the primary reason you became a teacher? >>>
Her primary reason to become a teacher was because it is something she has wanted to do
since childhood. There was also a scholarship at her school which helped pay for her to go into this
profession.

Interview Question 2: What are the main challenges you face as a teacher? >>>
Some of the main challenges she faces as a teacher is trying to help students that were absent
to catch up. She needs to find time in the schedule to bring the student up to date. Another challenge is
funding, there is very little provided and an extreme lack of resources.

Interview Question 3: What is the best part of being a teacher? >>>

The best part about being a teacher for her is to see her students succeed and to see
improvements in their scores. She says she works hard to make sure they understand what is being
taught and it means a lot to see them do well. She also enjoys getting to talk to the students and learn
about them.

Interview Question 4: How do you determine where students sit in class? >>>
She does it based off several things for starters she puts students with worse eyesight in the
front. Then she usually keeps students with behavior problems next to her desk. She tries to place the
students based on their assessments, so that they can help each other. If they are too noisy, she will
adjust the seating arrangements.

Interview Question 5: How do you determine the members of any flexible groups? >>>
She determines it by using data. She groups students with similar testing levels together and
pulls students that need extra help in their own groups together.

Interview Question 6: Beyond standardized testing, what assessments do you use regularly? >>>
The school district has two new programs to test assessments.

Interview Question 7: What requirements are placed on you for reporting progress to parents? >>>
They school sends home progress reports, but they also have access to their child's grades at
any time through the internet.

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Interview Question 8: How often do you interact with a student’s parents in person, and what type of discussions
do you typically have? >>>
She interacts with parents daily when the parents pick up their children. As for conferences it all
must be done online due to covid. There are also online resources which allow her to send
assignments she liked that the student did and keep them updated.

Interview Question 9: How much grading do you complete on a daily/weekly basis? >>>
It depends on the subject for math and reading are the most frequent done about every couple
days, science is done about once a week, and writing takes the longest since it takes longer to grade.

Interview Question 10: How long does it take to prepare lessons for the day/week? >>>
It takes her about 50 minutes to create a new lesson plan but around 20 minutes if it has
already been taught. The work is split among coworkers, so each teacher does one subject.

Interview Question 11: What procedures or strategies do you use to maximize instructional time? >>>
She uses countdowns to keep the class on track and positive reinforcement to motivate the
other students.

Interview Question 12: What positive reinforcement programs have you had success with, and what behavioral
consequences seem most effective with this age group? >>>
There are no real consequences the teacher can give. She can only remove the students from
the room or tell them they can't play a game. The school uses class dojo for rewards and if they have
good attendance, they get fine tokens which allows for snacks or extra recess when they earn enough.

Interview Question 13: How are specialist teachers involved in the instructional planning process? >>>
She says that they don’t play a large role in instructional time.

Interview Question 14: How often are you evaluated, and what measurement tool is used by the administration
for determining your teaching performance? >>>
She says since she has been there for so long, she is evaluated at least twice a year for about
30 minutes. She is evaluated using NEPF.

Interview Question 15: What consequences are there if your evaluation is not favorable? >>>
She said she has never received an unfavorable evaluation but assumes that they would get
guidance on how to improve.

Interview Question 16: What types of support do you receive instructionally, financially, or professionally from
the school, parent organization or school district to enhance instruction? >>>
She says there are no financial resources at all provided for them. They're provided books,
iPad’s, and training but besides that everything comes from out of pocket.

Interview Question 17: What surprised you most about teaching as a profession? >>>
She said she thought it would be a lot easier and more fun, but it is a lot more paperwork than
she anticipated.

ASSIGNMENT 6 (Observing a student): Discretely observe one student in your assigned classroom during an
extended period of direct instruction. Detail what was going on in the environment, and what you observed the
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student doing while the lesson was being given. Make sure to document ALL behavior in relationship to what was
being presented by the classroom teacher. Please describe the setting, the lesson that was given, if the student
was on task and engaged in the lesson, and what you uncovered about putting yourself in a lesson from the
student’s point of view.

The student I observed name is Jasmine. During every instruction she was always prepared
and ready to listen to the teacher. When doing math and social studies she always had the correct
answer but was hesitant to raise her hand to answer. When the teacher walked the classroom to see
answers, the teacher always said she had it correct. When trying to find two ways to multiply she had
come up with four different ways to do it. I learned just how important it is to offer students multiple
ways to get an answer. For example, to do multiplication the teacher had arrays, repeated addition
,distribution , and skip counting.

ASSIGNMENT 7 (Summary): Thoroughly summarize and reflect upon your entire 10 hour Field Observation
Placement.

I learned many great strategies during my observation such as how to manage time efficiently,

how to get the students attention, and how to run a classroom. The students in this class were all very

kind and extremely smart. These kids uses critical thinking and always seem so eager to learn more. The

teacher really seemed passionate about her profession and mentioned this was her 12 year teaching. The

environment of the whole school was super comforting and felt like a safe place. This observation

opened my eyes to many things such as how much time goes into making lesson, paperwork, and

grading. I think this has prepared my to become a teacher because I now know to start learning to have

better time management. In school its all about doing this efficiently and on time. In my education

classroom I have created many assignments in word or PowerPoint that seem to match closely to what I

had seen in the classroom which was reassuring. There was also a lot more technology involved in the

classroom than I initially though. Overall this was a great experience and I will implement much of what

I learned in my future class.

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Before final grading for EDU 201, EDU 202, EDU 203 courses can occur, the CSN student must submit their
completed Field Observation Activities Packet, Time Log, and Student Evaluation to their CSN instructor for
grading. The student must also provide the CCSD cooperating teacher with their CSN professor’s contact
information, so the cooperating teacher can send a quick email validation that the student completed their 10
hours before the final exam date.

The instructor’s email can be found on the first page of this packet, and on the next page.
Remember to save this completed packet in digital form, or as a hard copy for the
Education Department’s capstone course, (EDU 299)

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EXHIBIT'B STUDENTS'STATEMENT'OF'RESPONSIBILITY For and in consideration of the benefit
provided me in the form of training and clinical experience at the Clark County School district
(“DISTRICT”), hereafter designated as the “PROGRAM,” I acknowledge certain responsibilities. I,
Alexus Rosario Cornejo, understand that a Contract exists between my educational institution
(“INSTITUTION”) and DISTRICT to implement the PROGRAM to which this Student Statement of
Responsibility will be attached. I, on my own behalf and on behalf of my heirs, assigns and legal
representative, do hereby covenant and agree to assume all risks and to be solely responsible for any
injury or loss (including death) sustained by me while participating in the PROGRAM, unless such
injury or loss arises solely out of the negligence of DISTRICT or their employees. I will abide by
DISTRICT’s rules, policies, regulations and procedures, throughout the PROGRAM. I will notify both
INSTITUTION and designated DISTRICT employee if, for any reason, I will be absent from a
scheduled rotation, work shift, meeting or a PROGRAM activity. I agree that I am solely responsible for
my maintenance, support, living expenses, health insurance and transportation to and from DISTRICT
throughout the PROGRAM period. I understand and agree that my status with District throughout the
PROGRAM period is that of a student receiving education. For this reason, absent a formal offer of
employment, I have no expectation of receiving compensation from, or future employment with
DISTRICT. Should I obtain employment with the DISTRICT through a formal process, the
employment contract may supersede this clause regarding the expectation of compensation and future
employment. I have no expectation that I will be covered by DISTRICT’s workers’ compensation
policy. I hereby acknowledge and agree that I have been offered the opportunity to consult with my own
attorney concerning the contents of this Student Statement of Responsibility before signing it. I warrant
that I am at least 18 years of age; that I have read and understand the contents of this document; and that
I sign it freely and without reliance upon DISTRICT representations or promises. Dated this 1st day of
October 2021.

EXHIBIT'C STUDENT'CONFIDENTIALITY'STATEMENT
I, Alexus Rosario Cornejo, am a student at an educational institution (“INSTITUTION”), in
consideration of the training and clinical experience at the Clark County School District (“DISTRICT”),
hereafter designated as the “PROGRAM.” A Contract between DISTRICT and my INSTITUTION
exists and this Student Confidentiality Statement will be attached to that Contract. I hereby recognize
that while in the PROGRAM, I may encounter private information. This information includes but is not
limited to medical records; patient care information; personnel information; student education records;
reports to regulatory agencies; and conversations between or among healthcare professionals that are
considered privileged and should be treated with utmost confidentiality. I agree, under penalty of law,
not to disclose to any entity, person or persons, except authorized clinical staff and associated personnel
of DISTRICT, the above listed information. I further agree not to reveal to any third party any
confidential information of DISTRICT, except as required by law or as authorized by DISTRICT. I
hereby acknowledge and agree that I have been offered the opportunity to consult with my own attorney
concerning the contents of this Student Confidentiality Statement before signing it. I warrant that I am at
least 18 years of age; that I have read and understood my obligations under this Student Confidentiality
Statement; and that I sign it freely and without reliance upon any representations or promises by
DISTRICT or their employees. Dated this 1st day of October 2021.
Alexus Rosario Cornejo < Signature of Program Participant
Alexus Rosario Cornejo < Name (printed) of Program Participant

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