Date _________________                                                                                  School year __________________

All information provided in connection with this application will be kept confidential.

Name of student:  ____________________________________________  Grade in school __________________

Name of student:  ____________________________________________  Grade in school __________________

Name of student:  ____________________________________________  Grade in school __________________

Attendance Center/School  _____________________________________________________________________

Name of parent, guardian: ______________________________________________________________________
  or legal or actual custodian

Please check type of wavier desired:
                  Full waiver  _________  Partial waiver  _________  Temporary waiver  _________ 

Please check if the student or the student's family meets the financial eligibility criteria or is involved in one of the following programs:

Full waiver

_________  Free meals offered under the Children Nutrition Program (CNP)
_________  The Family Investment Program (FIP)
_________  Transportation assistance under open enrollment
_________  Foster care

Partial waiver

_________  Reduced priced meals offered under the Children Nutrition Program

Temporary waiver

If none of the above apply, but you wish to apply for a temporary waiver of school fees because of serious financial problems, please state the reason for the request:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Signature of parent, guardian:  __________________________________________________
  or legal or actual custodian

The board recognizes that while certain fees charged students are appropriate and authorized, certain students and their families are not financially able to pay the fees.  The school district will grant either full waivers, partial waivers or temporary waivers depending upon the circumstances and the student or student's parents' ability to meet the financial criteria.

        A.      Waivers -

                  1.   Full Waivers - a student will be granted a full waiver of fees charged by the school district if the student or student's parents meet the financial eligibility criteria for free meals under the Child Nutrition program, Family Investment Program, or transportation assistance under open enrollment.  Students in foster care are also eligible for full waivers.

2.   Partial Waivers - a student will be granted a partial waiver of fees charged by the school district if the student or the student's parents meet the financial eligibility criteria for reduced price meals offered under the Child Nutrition program.  A partial waiver is based on the same percentage as the reduced price meals.

                  3.   Temporary Waivers - a student may be eligible for a temporary waiver of fees charged by the district in the event the student's parents are facing financial difficulty.  Temporary waivers may be applied for at any time throughout the school year and will not extend beyond the end of the school year.

        B.       Application - Parents or students eligible for a fee waiver will make an application on the form provided by the school district.  Applications may be made at any time but must be renewed annually.

        C.       Confidentiality - The school district will treat the application and application process as any other student record and student confidentiality and access provisions will be followed.

        D.      Appeals - Denials of a waiver may be appealed to the Superintendent.

        E.       Fines or charges assessed for damage or loss to school property are not fees and will not be waived.

        F.       Notice - the school district will annually notify parents and students of the waiver.  The following information will be included in registration materials.

Students whose families meet the income guidelines for free and reduced price lunch, the Family Investment Program (FIP), or transportation assistance under open enrollment, or who are in foster care are eligible to have their student fees waived or partially waived.  Students whose families are experiencing a temporary financial difficulty may be eligible for a temporary waiver of student fees.  Parents or students who believe they may qualify for temporary financial hardship should contact the principal for a waiver form.  This waiver does not carry over from year to year and must be completed annually.

This form has been reviewed and completed by the undersigned employee.  A written copy of this form has been sent to the student’s parent or guardian within three school days of the occurrence.  Unless the parent or guardian agrees to receive the report by email, fax, or hand delivery, the report must be sent by mail and postmarked by the third day following the occurrence.  Enclosed with a copy of this form is an invitation for the parents or guardians to participate in the debriefing meeting scheduled in accordance with the law.

____________________________________  ______________________________
Employee                                                                               Date of form delivered to Parent/Guardian

_______________________________
Method of Transmittal

[This letter and the enclosed report may be transmitted electronically via email or fax, picked up in person, or mailed.  If the district and the guardian do not agree on how to transmit this letter, it must be mailed via postage prepaid, first class mail to the guardian within 3 school days of the occurrence.]

Dear [Guardian],

Recently, your student [name] was involved in an occurrence at school that required the physical restraint and/or seclusion of your student as defined by 281 Iowa Administrative Code Ch. 103.  A report related to this occurrence is enclosed with this letter.

The law requires debriefing meetings be held for such occurrences in the following circumstances:

• following the first instance of seclusion or physical restraint during a school year;
• When any personal injury occurs as a part of the use of seclusion or physical restraint;
• When a reasonable educator would determine a debriefing session is necessary;
• When suggested by a student’s IEP team;
• When agreed to by the guardian and school officials; and
• After seven instances of seclusion or physical restraint of the student.

This letter is intended to inform you that a debriefing meeting will be held on [date within 5 days of transmission of letter, time, place] because of [reason from bulleted list above].  The following employees will be in attendance at this meeting:  [list names and titles of employees].  We are inviting you to attend this debriefing meeting to engage with us on topics related to this occurrence.

If you would like to reschedule the debriefing meeting, please contact me as soon as possible via email [email address] or telephone [telephone number], and at least one school day prior to the date and time listed for this debriefing meeting.  Your student is allowed to attend this meeting with your consent, and you are welcome to bring a representative of your choosing if you wish.  If you plan to bring a representative to this meeting, please let us know at least one school day prior to the meeting so that we have an opportunity to make arrangements.

We look forward to working with you to foster the continued health, safety and educational growth of your student.

___________________________________  ___________________________
[Administrator name], title                                           Date

Enclosure:  Report related to student occurrence

[The following individuals must attend the debriefing meeting: employees who administered physical restraint or seclusion; an administrator or employee not involved in the occurrence; the administrator or employee who approved continuation of the physical restraint or seclusion; other relevant personnel designated by the school; if indicated by student’s behavior in occurrence, an expert in behavioral/mental health or other discipline.  The following individuals must be invited to attend the debriefing meeting:  the parent or guardian of the student, the student with guardian’s consent.]

This form has been reviewed and completed by the undersigned employee.  A written copy of this form has been sent to the student’s guardian within three school days of the debriefing meeting.

____________________________________  ______________________________
Employee                                                                                Date of delivered to Parent/Guardian

______________________________
Method of Transmittal

The District will comply with 281 Iowa Administrative Code Ch. 103 for the use of physical restraint and seclusion with students, including, but not limited to:

• Physical restraint and seclusion will be used only by employees who have been trained in accordance with applicable law unless a trained employee is not immediately available due to the unforeseeable nature of the occurrence.
• As soon as practical after the situation is under control, but within one hour after either the occurrence or the end of the school day, whichever occurs first, the school will attempt to contact the student’s parent or guardian using the school’s emergency contact system.
• The seclusion or physical restraint is used only for as long as necessary based on research and evidence to allow the student to regain control of their behavior to the point that the threat or behavior necessitating the use of the seclusion or physical restraint has ended, or when a medical condition occurs that puts the student at risk of harm.  Unless otherwise provided for in the student’s written approved IEP, BIP, IHP or safety plan, if the seclusion or physical restraint continues for more than 15 minutes:
• The student will be provided with any necessary breaks to attend to personal and bodily needs, unless doing so would endanger the child or others.
• An employee will obtain approval from an administrator or administrator’s designee to continue seclusion or physical restraint beyond 15 minutes.  After the initial approval, an employee must obtain additional approval every 30 minutes thereafter for the continuation of the seclusion or physical restraint.
• The student’s parent or guardian and the school may agree to more frequent notifications than is required by law.
• Schools and district employees must document and explain in writing the reasons why it was not possible for the employees to obtain approval, notify parents, or take action within prescribed time limits.
• Schools and district employees who begin and then end use of nonapproved restraints will document and explain in writing the reasons why they had no other option but to use this type of behavioral intervention.
• The area of seclusion will be a designated seclusion room that complies with the seclusion room requirements in accordance with law, unless the nature of the occurrence makes the use of the designated seclusion room impossible, clearly impractical, or clearly contrary to the safety of the student, others, or both; in that event, the school must document and explain in writing the reasons why a designated seclusion room was not used.
• An employee must continually visually monitor the student for the duration of the seclusion or physical restraint.
• If an employee restrains a student who uses sign language or an augmentive mode of communication as the student’s primary mode of communication, the student shall be permitted to have the student’s hands free of physical restraint, unless doing so is not feasible in view of the threat posed.
• Seclusion or physical restraint shall not be used:  as punishment or discipline; to force compliance or to retaliate; as a substitute for appropriate educational or behavioral support; to prevent property damage except as provided in law; as a routine school safety measure; or as a convenience to staff.
• The Superintendent or the Superintendent’s designee will investigate any complaint or allegation that one or more employees violated any provisions of 281 Iowa Administrative Code Ch. 103.  If the District determines a violation has occurred, corrective action will be taken up to and including termination of the employees involved.  If the allegation or complaint involves a specific student the District will notify the parents or guardian of the involved student about the results of the investigation.  If any allegation or complaint is also defined as abuse in 281 Iowa Administrative Code 102.2, the procedures listed in chapter 102 will apply.
• The District must comply with and implement Chapter 103 whether or not a parent consents to the use of physical restraint or seclusion.

Dear (Parent/Guardian) _________________,

This letter is to inform you that your student (student’s name listed on registration) ________________ has made a request of a licensed employee to (check all that apply):

______ make an accommodation that is intended to affirm the student’s gender identity as follows:  ______________________________________________________________________________________________________________________________________________________________________

______ use a name, pronoun or gender identity that is different from the name, pronoun and/or gender identity listed on the student’s school registration forms. The name, pronoun, or gender identity requested is _________________________________________________________________________. 

If you would like to amend the student’s registration paperwork to permit the student’s requested accommodation and/or include the use of the above-referenced name/pronoun/gender identity, please complete the attached form and return it to the district administration office.

Sincerely,

____________________________________________                                      __________________
Administrator                                                                                                                                    Date

__________________________________________________                                      __________________
(Student’s current name on registration)                                                                                             (Student ID)

Please update my student’s names, pronouns, and/or gender identities on my student’s registration paperwork to include all of the following:

__________________________________________________________________________________
(Names)

__________________________________________________________________________________
(Pronouns)

__________________________________________________________________________________
(Gender identities)

__________________________________                                                                            __________________
Parent/Guardian                                                                                                                                        Date

Effective student discipline policies serve the needs of the District in maintaining the order of the education environment while safeguarding the education interests of all students.  For this reason, it is crucial to engage many perspectives in crafting sound policies related to discipline. The board, in conjunction with teachers and administrators in the District, have assigned further meaning to concepts listed in this policy.

Incident Levels Defined

Incident levels must escalate, with Level 1 being less severe than Level 3 incidents. However, the District maintains discretion in applying the level of discipline appropriate for an incident. In making this determination, the administration will consider the following definitions of incident levels. Because no definition could encompass all possible threats or incidents, the administration has discretion in determining which level to assign the incident after looking at the nature of the incident as well as the age, grade level, and maturity of the student.

Level 1 Defined

• Disruptive or concerning behavior
• Student shows no sign of distress or low level of distress and disturbance
• Possible threat made or present
• Threat is vague and indirect
• Information about threat or threat itself is inconsistent, implausible, or lacks detail
• Threat lacks realism, or is repeated with variations
• Content of threat suggests student is unlikely to carry it out
• Seriously disruptive incident
• Threat made or present
• Threat is vague and indirect, but may be repeated or shared with multiple reporters

Level 2 Defined

• Student is disturbed or advancing to dysregulation
• Threat made or present
• Threat is vague, but direct, or specific but indirect
• Likely to be repeated or shared with multiple reporters
• Information about threat or threat itself is consistent, plausible or includes increasing detail of a plan (time, place, etc.)
• Threat is accompanied by talk or efforts to obtain weapons or other methods for harm
• Threat is likely to be repeated with consistency (may try to convince listener they are serious)
• Content of threat suggests student may carry it out

Level 3 Defined

• Student is dysregulated (way off baseline) or medically disabled
• Threat made or present
• Threat is concrete (specific or direct)
• Likely to be repeated or shared with multiple reporters
• Information about threat o threat itself is consistent, plausible, or includes specific detail of a plan (time, place, etc.) often with steps already taken
• Threat is accompanied by evidence of efforts to obtain weapons or other methods for harm
• Threat may be repeated with consistency
• Content of threat suggests student will carry it out (reference to weapons, means, target)
• Student may appear detached

Timeframe for Determining Repeated Incidents

The District will consider all incidents occurring within the school year as sufficiently close in proximity between incidents to establish that a repeated incident has occurred. The rationale for establishing this timeframe is safety for students and staff. The administration will have discretion to alter this timeframe when appropriate under the circumstances, depending on the nature of the incident as well as the age, grade level and maturity of the student.

Considerations for Determining the Maturity of the Student

The District believes that gauging the maturity of a student is subject to interpretation and best left to the licensed employees who interact most closely with the student on a regular basis.  Assessing a student’s maturity level is based on individual characteristics unique to each student. Therefore, in making a determination about the maturity of a student, the administration may consult with the student’s classroom teacher and other relevant licensed staff.  The administration will consider the following factors in determining the maturity of the student:
Staff feedback
Age of the student

Considerations for Determining Whether the Off-Campus Threat of Violence or Incident of Violence Will Directly Affect the Good Order, Efficient Management and Welfare of the School District

The District recognizes that students maintain First Amendment rights to free expression both within school and outside. However, free speech protections are not absolute and do not extend to true threats of violence toward an individual or a group of individuals. In considering whether a threat or incident of violence will directly affect the good order, efficient management and welfare of the school district necessitating the need for investigation, the administration will consider, among other things, the following factors:

• The specificity of the threat for time, location or individual(s) targeted
• The reasonable likelihood of the student’s ability to carry out the threat
• The reasonable likelihood that the threat will interfere with the operation of the educational environment

In addition to the notification requirements in policy, the administration will apprise the parents or guardians of any student who suffered violence or a threat of violence, of the rights to file complaints under any other relevant board policies including but not limited to anti-bullying/anti-harassment and Title IX.

Legal Reference:     Iowa Code §279.79