SAMPLE
XYZ Charter
719 Fourth Street
Anytown, TX
555/555-1234
Student Agreement Form -
Acceptable Use Policy
Electronic
Communications System and Network
Please read the
following information carefully.
Parent and student must
sign this form.
The student must return
the signed form to his/her Language Arts/English teacher.
STUDENT:
I understand that my use of the network is not private and
that the school may monitor my activity on the system. I have read and understand the rules for
appropriate use. I understand that
violation of these rules may result in suspension of the right to use the
system or other disciplinary action at the discretion of the school.
Date: _____________________________________________________________________________
Student
signature: ___________________________________________________________________
Print
student name: __________________________________________________________________
PARENT OR GUARDIAN:
I have read the rules for appropriate use of the system and
network and the potential actions that may be taken for inappropriate use. In consideration for the privilege of my child
using the system and in consideration for having access to public networks, I
hereby release from any and all claims and damages of any nature arising from
my child's use of the system, including and without limitation to damages
associated with school enforcement of this policy.
Parent
or guardian signature: __________________________________________________________
Print
name: ________________________________________________________________________
Address:
__________________________________________________________________________
Home
Phone: ____________________________________ Date: _____________________________
Work
Phone: ________________________ Email address: __________________________________