AC-E5

File:  AC-E5 (pdf)
May 10, 2016

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CONFIDENTIAL
GENDER SUPPORT PLAN

The purpose of this document is to create shared understandings about the ways in which the student's authentic gender will be accounted for and supported at school. School staff, caregivers and the student should work together to complete this document. Ideally, each will spend time completing the various sections to the best of their ability and then come together to review sections and confirm shared agreements about using the plan. Please note that there is a separate document to plan for a student's formal gender transition at school.

School:_________________________________

Today’s Date:_____________________

Student’s Preferred Name: _________________________________________________

Legal Name: ____________________________________________________________

Student’s Gender:_________________________

Assigned Sex at Birth:______________________

Student Grade Level:_______________________

Date of Birth:______________________________

Sibling(s)/Grade(s):
___________________________________(_____)/
___________________________________(_____)/
___________________________________(_____)/
___________________________________(_____)

Parent(s)/Guardian(s)/Relation to Student:
_________________________(_________________________)/
_________________________(_________________________)/
_________________________(_________________________)/
_________________________(_________________________)

Meeting Participants:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

PARENT GUARDIAN INVOLVEMENT

Are guardian(s) of this student supportive of their child’s gender status?  ____Yes ____No
If not, what considerations must be accounted for in implementing this plan? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

CONFIDENTIALITY, PRIVACY AND DISCLOSURE

How public or private will information about this student's gender be (check all that apply)?

   ___ District staff will be aware (Superintendent, Student Support Services, District Psychologist, etc.)
          Specify the adult staff members:_____________________________________

   ___ Site level leadership/administration will know (Principal, head of school, counselor, etc.)
          Specify the adult staff members:_____________________________________

   ___ Teachers and/or other school staff will know
          Specify the adult staff members:_____________________________________

   ___ Student will not be openly "out," but some students are aware of the student's gender
          Specify the students:______________________________________________

   ___ Student is open with others (adults and peers) about gender

   ___ Other - describe: ________________________________________________________
          ______________________________________________________________________
          ______________________________________________________________________

If the student has asserted a degree of privacy, what are expectations of the institution if that privacy is compromised? How will a teacher/staff member respond to questions about the student's gender from:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
 

Other students? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Staff members? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

STUDENT SAFETY

Who will be the student's "go to adult" on campus?
___________________________________________________________________________

If this person is not available, what should student do? ___________________________________________________________________________
___________________________________________________________________________

What, if any, will be the process for periodically checking in with the student and/or family? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

What are expectations in the event the student is feeling unsafe and how will student signal need for help:
During class
___________________________________________________________________________

On the yard ___________________________________________________________________________

In the halls ___________________________________________________________________________

Other
___________________________________________________________________________

Other Safety concerns/Questions ___________________________________________________________________________

NAMES, PRONOUNS AND STUDENT RECORDS

Name/gender marker entered into the Student Information System: ___________________________________________________________________________

Name to be used when referring to the student: ___________________________________________________________________________

Pronouns:___________________________________________________________________

Can the student's preferred name and gender marker be reflected in the SIS? If so, how? ___________________________________________________________________________
___________________________________________________________________________

If not, what adjustments can be made to protect this student's privacy? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Who will be the point person for ensuring these adjustments are made and communicated as needed? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

How will instances be handled in which the incorrect name or pronoun are used? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

How will the student's privacy be accounted for and maintained in the following situations or contexts:
During registration ___________________________________________________________________________

Completing enrollment ___________________________________________________________________________

With substitute teachers ___________________________________________________________________________

Standardized tests
___________________________________________________________________________

School photos
___________________________________________________________________________

lEPs/Other Services
___________________________________________________________________________

Student cumulative file
___________________________________________________________________________

After-school programs
___________________________________________________________________________

Lunch lines
___________________________________________________________________________

Taking attendance
___________________________________________________________________________

Teacher grade book(s)
______________________________________________________________________________

Official school-home communication
___________________________________________________________________________

Unofficial school-home communication (PTS/other)
___________________________________________________________________________

Outside district personnel or providers
___________________________________________________________________________

Summons to office
___________________________________________________________________________

Yearbook
___________________________________________________________________________

Student ID/library cards
___________________________________________________________________________

Posted lists
___________________________________________________________________________

Distribution of texts or other school supplies
___________________________________________________________________________

Assignment of IT accounts
___________________________________________________________________________

What are some other ways the school needs to anticipate information about this student's preferred name and gender marker potentially being compromised? How will these be handled? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

USE OF FACILITIES

Student will use the following restroom(s) on campus:
___________________________________________________________________________

Student will change clothes in the following place(s):
___________________________________________________________________________

If student has questions/concerns about facilities, who will be the contact person?
___________________________________________________________________________

What are the expectations regarding the use of facilities for any class trips?
___________________________________________________________________________

What are the expectations regarding rooming for any overnight-trips?
___________________________________________________________________________

Are there any questions or concerns about the-student's access to facilities?
___________________________________________________________________________

EXTRACURRICULAR ACTIVITIES

Does the student participate in an after-school program?     _____Y     _____N
What steps will be necessary for supporting the student there?
___________________________________________________________________________

In what extra-curricular programs or activities will the student be participating (sports, theater, clubs, etc.)?
___________________________________________________________________________
___________________________________________________________________________

What steps will be necessary for supporting-the student there? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Questions/Notes:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

OTHER CONSIDERATIONS

Are there any specific social dynamics with other students, families or staff members that need to be discussed or accounted for?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Does the student have any sibling(s) at school?  _____Y     _____N    
Factors to be considered regarding sibling's needs?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Does the school have a dress code?  _____Y     _____N          
How will this be handled? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Are there lessons, units, content or other activities coming up this year to consider (growth and development, social justice units, name projects, dance instruction, Pride events, school dances etc.)? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

What training(s) will the school engage in to build capacity for working with gender-expansive students? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Are there any other questions, concerns or issues to discuss? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

SUPPORT PLAN REVIEW AND REVISION

How will this plan be monitored over time? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

What will be the process should the student, family, or school wish to revisit any aspects of the plan (or seek additions to the plan)? ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

What are specific follow-ups or action items emerging from this meeting and who is responsible for them?

Action Item	Who?	When?

 

Date / Time of next meeting or check-in: ___________________________________________________________________________

 

Location:
___________________________________________________________________________

 

Exhibit:
End of File: