User's Address _____________________________________________ __________________ __________________
  City      State Zip Code

User's Age ___ Date of Birth ________ Sex ___ Phone Number __________ School _______________

User's Grade __________________________ Homeroom ______________________________________

Please check if you are a ____ student _____ certified employee _____ classified employee

As a user of the Bullitt County Public School District's computer network, I hereby agree to comply with the District's Internet and electronic mail rules and to communicate over the network in a responsible manner while abiding by all relevant laws and restrictions. I further understand that violation of the regulations is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked and school disciplinary action and/or legal action may be taken.

User's Name (please print) ________________________________________________________________

User's Signature _______________________________________________ Date ___________________

Students will be supervised by a staff member during any Internet access.

As the parent or legal guardian of the student signing above, I grant permission for my child to access networked computer services such as the Internet. I understand that my child will be supervised while selecting, researching, sharing, or exploring electronic information and media; however I realize that some objectionable materials could be inadvertently encountered.

Name of Parent/Guardian (please print) _______________________________________________________

Signature of Parent/Guardian________________________________________________ Date _________

Daytime Phone Number: _______________________             Evening Phone Number: ___________________