Protocol and Consent Form

Which program are you applying for?*

Please select the relevant program

Student's Name:*

First Last

Do you have another student that you would like to add to this form?

Yes, I'd like to add another student to this form
No, I don't need to add anymore students

Second Student's Name:*

First Last

Do you have another student that you would like to add to this form?

Yes, I'd like to add another student to this form
No, I don't need to add anymore students

Third Student's Name:*

First Last

Do you have another student that you would like to add to this form?

Yes, I'd like to add another student to this form
No, I don't need to add anymore students

Fourth Student's Name:*

First Last

Link to the Code of Conduct

I have read the Code of Conduct and understand my child's responsibilities*

I agree

Link to the Technology Rights and Responsibilities

I have read the Technology Rights and Responsibilities document and understand my child's responsibilities*

I agree

Link to the School Emergency Program Guide

I have read and understand the School Emergency Program Guide*

I agree

I have read the information contained in the Outside Media Consent and understand that outside media may on occasion be authorized by the school to be present at the school, at school events or at public events where students are present. I understand that the School does not control the images or material printed by external media, and that it is my responsibility to communicate with the school if I have a concern about the collection of my child's image or information by external media that are authorized by the school to be present on school property or at school events.

Outside Media Consent response:*

Yes, I agree that my child's image may be published by outside media.
No, I do not authorize outside media to have access to my child or any information or images of my child for publication. (I understand my child will not be in the graduation insert in the newspaper - if applicable.)

I have read the information contained in the Personal Information Consent and understand that outside media may on occasion collect photographs, video or electronic images of students or their work for publication on the School's website or in other publications for the purposes of recognizing student or school achievement, promoting school activities or events, or informing the school community and members of the public about school programs and activities.

Personal Information Consent response:*

Yes, I consent to the collection, use and disclosure of my child's image and work product for the purposes described above and in the Personal Information Consent.
No, I do consent to the use of my child's image or work product as described above.

Link to the Media & Website Consent of Storage & Access of Information

I have read and understand the Media & Website Consent of Storage & Access of Information*

I agree

Consent: I understand that the information my child’s teacher and my child may create and store could be stored in or accessed from a location outside of Canada, and I hereby consent, on behalf of me and my child, to my child’s information identified above being stored in, or accessed from, a location outside of Canada. Permission to use the tools indicated above is granted for the duration of my child’s time in School District 71 (Comox Valley).

If you do not consent to the above statement or if you would like to remove consent in the future then please contact your program administrator and we will place a note in the student’s file.

Further details we should know:

Parent / Guardian #1*

First Last

Parent / Guardian #2

First Last

Parent / Guardian #1 email*

Parent / Guardian #2 email

Parent / Guardian #1 - Signature*

Parent / Guardian #2 - Signature

Protocol and Consent Form

Navigate-NIDES – Mailing Address:

Navigate-NIDES – Phone / Fax: