(This form should be printed (or a copy may be obtained at the Media Center), signed, and returned to the Media Center of your child's school. The original document will be kept on file there, and the student will be given a photocopy to present when using the Internet at school.)

I give my permission for ____________________________ to participate in the use of the Internet, a worldwide telecommunications network. I realize the (s)/he may be able to access major networks throughout the world using the Internet. I understand that this access is designed and intended for educational purposes only. I also understand that (s)he will receive instruction in the appropriate use of this resource.

I realize that the Internet contains material that is inappropriate for school purposes. I support the school district's position that students are responsible for not accessing such material. Such unacceptable use of the Internet will result in the suspension of all privileges. I will not hold the Governor Wentworth Regional School District accountable for unsuitable materials acquired by her/him through Internet usage at school.

I acknowledge that ____________________________ and I have read the Governor Wentworth Regional School District Acceptable Use Policy and this authorization form.

Parent/Guardian's name: _________________________________________________________

Parent/Guardian's Signature: _________________________________________Date ________

I understand that the use of the Governor Wentworth Regional School District Internet access is a privilege and will abide by the Governor Wentworth Regional School District Acceptable Use Policy. I understand that the Internet contains material inappropriate for school use and, therefore, will take personal responsibility not to access this material. I recognize that it is impossible for the Governor Wentworth Regional School District to prevent access to all controversial materials and I will not hold the Governor Wentworth Regional School District responsible for materials found or acquired on the Internet. I further understand that any violation of the regulations in this policy is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked, and appropriate school discipline and/or legal action may be taken.

Student Name: ________________________________________________ Grade _____

Student Signature: _____________________________________________ Date: _____

School Name: ___________________________________________________________