Student Email Account Request Form

Return to 4J Computing and Information Services (CIS)
200 N. Monroe
Eugene, OR 97402

CIS will return a copy of this completed form to the building computer rep.

____Check here if new account

____Check here if renewing account

Current USERNAME______________________________

Student Section

Student Name_____________________________Grade_________
Student Signature________________________________________
School___________________________________

I have read the Technology Appropriate Use Guidelines, and I agree to follow the guidelines/rules contained in this policy. I understand that if I violate the policy my account with 4JNET can be terminated and I may face other disciplinary measures as specified in the Guidelines, or in the District's Student Rights and Responsibilities Handbook.

In addition to the parent signature, elementary students are required to obtain a 4J educator's signature.
4J Educator's Signature______________________________ Date_____________

Parent or Guardian Section

I have read the information provided by Eugene 4J on student access to 4JNet. If remote access is provided from our home, I accept responsibility for at-home supervision.

I will instruct my child regarding any values against accessing materials that I have in addition to the restrictions set forth in the Technology Appropriate Use Guidelines, and I will emphasize to my child the importance of following the guidelines for student responsibility on the Internet.

Parent or Guardian Name________________________________Date__________
Parent or Guardian Signature_____________________________Date __________
Home Address__________________________________Phone_______________

This space reserved for System Administrator

Assigned User Name:___________________Assigned Temporary Password: __________________