Student Information
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Name of person completing this form
Date
03
/
26
/
2025
Email address for person completing this form
(this email address will receive a link for returning to complete your form)
Student Information
Pathways School (select location):
Select one
Anne Arundel-1819 Bay Ridge Ave. Ste. 340, Annapolis MD 21403 - 410-295-1539
Catonsville - 405 Frederick Road, Ste 110, Catonsville, MD 21228
Edgewood - 4600 Powder Mill Rd. Ste. 100, Beltsville, MD 20705 301-595-3483
Select one
Student Name (First)
(Middle)
(Last)
Date of Birth:
MM
/
DD
/
YYYY
Last 4 digits of SS#:
Current Grade:
Student's Home Address - Street:
City, State, Zip Code:
Home County/District:
Allegany
Anne Arundel
Baltimore County
Baltimore City
Calvert
Carroll
Cecil
Charles
District of Columbia
Frederick
Garrett
Harford
Howard
Montgomery
Prince George's
Queen Anne's
St. Mary's
Talbot
Washington
Wicomico
Select One
New Choice (18)
New Choice (19)
New Choice (20)
New Choice (21)
New Choice (22)
Select One
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Parent/Guardian Information
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
Parent / Guardian # 1 Name
Parent/ Guardian #1 relationship
Parent / Guardian # 1 Street
Parent / Guardian #1 City, State, Zip Code:
#1 Cell Phone
#1 Home Phone
#1 Work Phone
Parent/Guardian #1 Email
Parent / Guardian # 2 Name
Parent/ Guardian #2 relationship
Parent / Guardian # 2 Street
Parent / Guard. #2 City, State, Zip:
#2 Cell Phone
#2 Home Phone
#2 Work Phone
Parent/ Guardian #2 Email
*
*
In case of an emergency
and a parent/ guardian cannot be contacted, please identify 2 people the school may contact
:*
*
Emergency Contact #1 Name
Relationship
Phone
Emergency Contact #2 Name
Relationship
Phone
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
The federal government, which requires all states to collect information, has developed a way to report ethnicity and race that includes categories. These categories provide a more accurate picture of the nation’s ethnic and racial diversity. It also enables individuals to be identified in ethnic and racial classifications and in more then one racial category. These categories are for use in state and federal data collections that include data on ethnicity and race.
Ethnicity Designation
Is the student HISPANIC OR LATINO? Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, are considered Hispanic or Latino.
Yes
No
Race Designation
Read the descriptions below and check the box or boxes that indicate this student’s race. You must select at least one race, regardless of ethnicity designation. More than one response can be selected.
Indicate the student's race (Select all that apply)
AMERICAN INDIAN OR ALASKAN NATIVE: A person having origins in any of the original peoples of North or South America (including Central America), and who maintains a tribal affiliation or community attachment.
ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
BLACK OR AFRICAN AMERICAN: A person having origins in any of the black racial groups of Africa.
WHITE: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Parent/guardian initials:
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
MEDICAL INSURANCE INFORMATION
Doctor's Name / HMO:
Phone
Address:
Does your son/ daughter have health insurance?
yes
no
If yes, Medical Assistance ?
yes
no
Medical Insurance Company
policy #
Please list allergies or other special medical conditions:
** NOTE
If student takes any medications, please complete the Medication Forms
available at
https://pathwayschools.org/wp-content/uploads/2019/06/1_MedicationForm.pdf
School officials may administer first aid and/or take your child to the nearest appropriate medical facility in the event of a medical emergency.
IMPORTANT NOTE: Emergency personnel will be contacted and used, as deemed necessary, in emergency situations.
yes
no
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
Consent for Adult Services and College Fairs/Visits
I give permission for Pathways to invite a representative from the following agencies to attend IEP meetings and other meetings related to transition planning throughout the schools year (check all that you permit to be invited):
Division of Rehabilitation Services (DORS) - Vocational Rehabilitation Services
Developmental Disabilities Administration (DDA)
Behavioral Health Administration (BHA)
Department of Labor, Licensing and Regulation (DLLR) Office of Workforce Development and Adult Learning
I give permission for Pathways to refer my child to the following agencies during the school year (check all that you permit for a referral to be sent):
Div. of Rehabilitation Services (DORS) - Pre-Employment Transition Services (Pre-ETS)
Division of Rehabilitation Services (DORS) - Vocational Rehabilitation Services
Developmental Disabilities Administration (DDA)
Behavioral Health Administration (BHA)
Department of Labor, Licensing and Regulation (DLLR) Office of Workforce Development and Adult Learning
I give permission for my child to attend College Fairs/Visits and to request information from colleges in attendance at the college fair:
yes
no
Parent/guardian initials:
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
Once my son/daughter is enrolled at The Pathways Schools,
I give my permission for the school or contracted personnel to administer assessments
. The purpose of these assessments is to update academic skill levels and to identify post-secondary interests and career goals and interests.
This list is not intended to be all inclusive, but rather to give examples of the types of assessments that may be given.
The assessments given may include the following:
> Woodcock-Johnson Psycho-Educational Battery - Tests of Achievement IV
> QRI-6 (Qualitative Reading Inventory)
> Informal Assessments: Mathematics Assessments 6-8, Mathematics Assessment 9-12, Classroom Mathematics Inventory K-6, For the Teacher on the Go.....(reading and writing)
> Transition Assessments
> Functional Behavior Assessment (FBA)/Behavior Intervention Plan (BIP)
I understand that I may receive the results of the above or any other testing and have those explained to me. I also understand that all testing results will be treated with confidentiality. Only the parents/legal guardians, LSS and school staff that work with or provide services to the student are permitted access to this information unless I give my permission in writing.
Yes
No
Parent/guardian initials:
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
MEDIA/PHOTOGRAPHIC RELEASE FORM
This release shall be in effect the date of signature and shall extend for the duration of the
2024-2025
school year at Pathways, unless revoked in writing at any time.
Please check yes or no for each of the statements below.
The Pathways Schools has my permission to take photographs/video of student for use within The Pathways Schools
Yes
No
Print/release photographs or video of student WITH name included for publication, including on The Pathways Schools’ website, social media (e.g., Facebook) and newsletter
Yes
No
Print/release photographs or video of student WITHOUT name included for publication, including on The Pathways Schools’ website, social media (e.g., Facebook) and newsletter
Yes
No
Print/release written, artistic, or academic student work WITH name included for publication, including on The Pathways Schools’ website, social media (e.g., Facebook)
Yes
No
Print/release written, artistic, or academic student work WITHOUT name included for publication, including on The Pathways Schools’ website, social media (e.g., Facebook) and newsletter
Yes
No
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
PERMISSION FOR SCHOOL TRANSPORTATION DURING THE SCHOOL DAY
This permission shall be in effect the date of signature and shall extend for the duration of the
2024 – 2025
school year and
ESY 2025
, unless revoked in writing at any time.
I give my permission to The Pathways Schools, or person(s) operating on its authorized behalf, to have my son/daughter, participate in and be transported for activities, such as, but not limited to:
> community-based educational experiences and
> transition experiences, including job exploration, visits to vocational training sites, job shadowing experiences, volunteer and paid work, or internships.
I understand that at any time transportation may be provided:
> by a staff member with or without another staff member and my child
> by a staff member with or without another student
> in a staff member's vehicle; or
> in a Pathways vehicle.
Yes
No
Other
If "no" or "other", please explain:
Parent/guardian initials:
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Informed Consent for Telehealth Services and Distance Learning - Description
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
Introduction
Distance learning and telehealth involve the use of electronic communications to enable educators and related service practitioners to provide services for the purpose of IEP implementation. The information exchanged and obtained through distance learning and telehealth may be used for diagnosis, therapy, follow-up and/or education, and may include all of the following:
> Student records
> Medical records and images
> Live two-way audio and/or video
> Output data from sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of student identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits
> Improved access to services by enabling a student to remain in his/her home (or at a remote site) to receive IEP prescribed services from a healthcare practitioner at a distance/other site(s).
> Continuation of IEP prescribed services.
Possible Risks
As with any service, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
> Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by a practitioner;
> Delays in service could occur due to deficiencies or failures of the equipment and technology;
> In rare instances, security protocols could fail, causing a breach of privacy of personal identifiable information
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Informed Consent for Telehealth Services and Distance Learning - Consent
Student's First Name
Student's Last Name
Date
03
/
26
/
2025
By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of student information also apply to distance learning and telehealth, and that no information obtained in the use of distance learning or telehealth, which identifies the student, will be disclosed to researchers or other entities without my consent.
2. I understand that the student/parent have the right to withhold or withdraw consent to the use of distance learning or telehealth in the course of service provision at any time, without affecting the student's right to future service or treatment.
3. I understand that the student/parent have the right to inspect all information obtained and recorded in the course of a distance learning or telehealth interaction, and may receive copies of this information.
4. I understand that a variety of alternative methods of service provisions may be available, and that the student/parent may choose one or more of these at any time. The practitioner can explain the alternatives to the student's/parent’s satisfaction.
5. I understand that distance learning and telehealth may involve electronic communication of personal identifiable information (PII) to other service practitioners who may be located in other areas, including out of state.
6. I understand that the student/parent may expect the anticipated benefits from the use of distance learning or telehealth, but that results cannot be guaranteed or assured.
Student/Parent Consent to the Use of Distance Learning and Telehealth (select one)
GIVE INFORMED CONSENT - I have read and understand the information provided above regarding telehealth, have discussed it with the practitioner(s) or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give informed consent for the use of telehealth for the continuous implementation of the student's IEP.
DO NOT GIVE INFORMED CONSENT - I have read and understand the information provided above regarding telehealth, have discussed it with the practitioner(s) or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby Do Not give informed consent for the use of telehealth for the continuous implementation of the student's IEP.
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The Pathways
Schools ~ 2024-2025
Student Information and Consent Forms
Student's First Name
Student's Last Name
I understand
The Pathways Schools Student/Parent Handbook and site-specific handbooks
are available on The Pathways Schools website at
www.pathwayschools.org
I understand that the techniques and disciplinary actions for managing inappropriate behavior described in The Pathways Schools Parent Handbook include general separation, student requested time-out, staff directed time-out, lunch detention, community/school service, in-school intervention, search and seizure, suspension, alternative placement, and termination or expulsion. The Pathways Schools does not utilize physical restraint, exclusion or seclusion
Yes
No
Typing my name here acknowledges that all of the information and consents included in these forms is accurate to the best of my knowledge.
Type full first and last name
Date
03
/
26
/
2025
Verification
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