Policy 216.
2 Forms
MAINTENANCE OF STUDENT RECORDS – LEGAL NAME CHANGE
Request for Legal Name Change on a Students’ Official Record.
a. Date of Request: _____________________
b. Requested by (select one): Parent/Guardian Eligible Student
c. Student’s Prior Legal Name: ______________________________________________________________________
(First) (Middle) (Last)
d. Student’s New Legal Name: _________________________________________________________________________
(First) (Middle) (Last)
e. Legal Document reflecting the Legal Name Change (select one):
____ Birth Certificate ____ State or Federal Issued Identification
____ Passport ____ Other. Please Describe: _________________________________
____ Court Order
Parent/Guardian or Eligible Student Name: ______________________________________________________
Parent/Guardian or Eligible Student Signature: ________________________________________________________
(Applicant will be asked to produce the original document.)
For Admin Use Only
Disposition:
Policy 216.2 Forms
MEANS OF ADDRESSING STUDENTS – UNOFFICIAL NAME CHANGE REQUESTS
Accommodation request for student to be referred to differently from the district’s standard of referring to students by legal first, middle or last
name, a derivative of those names, or a nickname commonly associated with the student’s name.
a. Date of Request: _____________________
b. Student’s Legal Name: ______________________________________________________
c. Student’s Requested Name: ______________________________________________________
d. If you are requesting the district also update non-official school records with the student’s preferred name/nickname, circle:
a. Classroom roster;
b. Second diploma at the student's expense with the student’s preferred name in addition to the diploma with the student’s
legal name?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Parent/Guardian or Eligible Student Name: ______________________________________________________
Parent/Guardian or Eligible Student Signature: ________________________________________________________
For Admin Use Only
Disposition:
Policy 216.2 Forms
MAINTENANCE OF STUDENT RECORDS – GENDER IDENTITY
Accommodation Request to Add Gender Identity Different from Student’s Sex to Records.
a. Date of Request: _____________________
b. Requested by (select one): Parent/Guardian Eligible Student
c. Student’s Name*: ______________________________________
Please specifically name the gender identity (such as transgender boy, transgender girl, agender, aporagender, demigender,
pangender, etc.) and any requested pronoun related to such identity: ______________________________________
d. If relevant to an accommodation request, please state how the student has consistently, persistently, and insistently expressed the
named identity and/or any other information:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
*If requesting the school to utilize a different name, please also fill out the “Means of Addressing Students” form
e. By signing below, the undersigned relieves the board and district employees of liability for participating in social transition
treatments.
Parent/Guardian or Eligible Student Name: ______________________________________________________
Parent/Guardian or Eligible Student Signature: ________________________________________________________
(Legal documents reflecting changes in gender identity are not required for requests to update gender identity information in school records.)
For Admin Use Only
Disposition:
