Long Term Sub Account

Legal First Name:*

Last Name:*

Preferred Name:

Middle Name:

Street Address:*

City, State, Zip:*

Home Phone:*

Date of Birth:

Current Email Address (for contact purposes):*

Position Title:*

Location (School or Other):*

Faculty/staff member you will be substituting for*

Date Service Begins:*

Date Service Ends:*

Are you contracted through Kelly Services?:*

Yes No

Special Programs (Special Ed)*

Yes No

PowerSchool (Student Management System) access equal to:*

Teacher Office User Student Nurse Other (Please attach)

Network access equal to:*

Teacher Office User Student Nurse NA

Enter Department and/or Grade Level if Applicable:*

Acknowledgements

I have received and am knowledgeable of the content in the revised Technology Usage Policy adopted by the Mountain Brook Board of Education in May, 2011 and the Data Governance Policy.

Type your name to acknowledge the above:*

Date Acknowledged:*

A local school technology coordinator, the data specialist, or the technology director will contact you concerning the status of your accounts. Once you are on site, together you will review the basic of acceptable technology and data use, the available technologies, and procedures for receiving technical assistance. At this time, your account will be enabled and ready for use.

*Accounts are disabled on the last day of active employment.

If there is additional information that is specific to the account requested, attach file here:

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Any additional information:

Please scroll down to the bottom of this form to Submit.

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To be completed by Technology Department

Account has been created in PowerSchool

Yes No

Notes:

(Coord.) Upload scanned, signed Data Confidentially Form:

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Data Specialist Enables Account: