St. Clare Walker Middle School Signature Forms 2021-22
Please use this form to acknowledge receipt of the Parent/Student Handbook (https://sites.google.com/mcps.k12.va.us/mcpsstudenthandbook2021-2022/mcps-parent-student-handbook) and indicate your preferences below.  The electronic record of this submission will be maintained as part of your child's record.
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Parent/Guardian Last Name *
Parent/Guardian First Name *
Parent/Guardian Primary Phone Number *
Parent/Guardian Email Address *
Home Address *
Street Address, Town, Zip Code
Mailing Address *
Student Last Name *
Student First Name *
Student's Current Grade Level: *
Report Card *
Do you want to receive paper copies of your child's report card? NOTE: Parents/Guardians have 24/7 online access to grades in PowerSchool at mcps.powerschool.com/public/ (Contact your child's school for login information)
Code of Conduct *
Please type your FULL NAME BELOW to acknowledge that you have access to the Middlesex County Public Schools’ Student Code of Conduct and Parental Responsibilities Acknowledgement and understand that your child is responsible for adhering to these policies.
Medicaid Reimbursement *
Do you give MCPS permission to bill Medicaid for eligible services provided to your child? (Medicaid will reimburse MCPS for eligible expenses and services if you allow this)
Cell Phone Provisions *
Please type your FULL NAME BELOW to acknowledge that you understand the Middlesex County Public Schools student cell phone provisions outlined in the handbook at mcps.powerschool.com/public/
Cell Phone Permission *
I approve that my child may carry a cell phone to school and follow the rules outlined in the manual and instructions specific to my child's school.
Student's personal cell phone number
My child has permission to work with the certified therapy dog. *
Acceptable Use Policy *
Please type your FULL NAME BELOW to acknowledge that you understand the policy regarding the acceptable use and protocols for the use of computers and networks that are the property of Middlesex County Public Schools.  Further, you understand the possible consequences that may ensue for violating this policy.
Family Life Education *
Please type your FULL NAME BELOW to acknowledge that you understand that you will be provided your child’s grade-level Family Life Education standards of learning.  Additionally, you understand that prior to any FLE lessons being presented during the course of teaching the required curriculum, you have the right to “opt out” and hav your child removed from the classroom for that portion of the curriculum.
Use of Student Information *
Middlesex County Public Schools positively promotes its programs, activities, and accomplishments throughout our community and region.  As such, press releases, web postings and school publications are encouraged as a means of informing the public.  Federal law permits the disclosure of “directory information” from student records without the parents’ prior written consent.  Unless a parent has refused permission, Middlesex County Public Schools may use or disclose directory information including a student’s name, age, school, and grade, awards or honors, artwork, and/or image for school-sponsored publications.
Athletic Handbook (8th grade only)
Please type your FULL NAME BELOW to acknowledge that you have access to the Student Athletic Handbook at www.mcps.k12.va.us.  The purpose of this Handbook is to provide pertinent information regarding participation in the MCPS VHSL Athletics and Activities programs.  I have read and understand that my student-athlete and I are responsible upholding the guidelines set forth in this handbook.  We also acknowledge we have received information pertaining to the dangers of concussions.
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