503.3E1

Standard Fee Waiver Application

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:  _______

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 waiver desired:  

            _____ Full Waiver            _____ Partial waiver          

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

Full Waiver:

_____     Free meals offered under the Child Nutrition Program(CNP)

_____     The Family Investment Program(FIP)

_____     Transportation assistance under open enrollment

_____     Foster Care

Partial Waiver:                       

     _____      Reduced priced meals offered under the Child Nutrition Program

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

Cross Reference:

    501.16    Homeless Children and Youth

Approved:  02/10/1997    Reviewed: 03/18/2024    Revised: 03/18/2024

Code No.  503.6E1

Page 1 of 3

USE OF PHYSICAL RESTRAINT AND/OR SECLUSION DOCUMENTATION FORM

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

Approved:   2/8/2021                                        Reviewed:                                                             Revised:  

[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

Approved:    2/8/2021        Reviewed:            Revised:

Code No.  503.6E3

Page 1 of 2

DEBRIEFING MEETING DOCUMENT

[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

Approved:      2/8/2021                                     Reviewed:                                                    Revised:

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.

Approved:     2/8/2021                                  Reviewed:                                      Revised:

TIPTON COMMUNITY SCHOOL DISTRICT

REPORT OF STUDENT DISCLOSURE OF IDENTITY

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

Approved:  08/14/2023                 Reviewed:  ____________                   Revised:  ____________

Board Policy:  503.7E2

TIPTON COMMUNITY SCHOOL DISTRICT

REQUEST TO UPDATE STUDENT IDENTITY

__________________________________________________            __________________

(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

Approved:  08/14/2023           Reviewed:  ______________              Revised:  ___________

Please see attached PDF

Approved:  02/12/2024    Reviewed:  ______________  Revised:  _______________