Northeastern Regional Information Center
1031 Watervliet-Shaker Road, Albany, NY 12205  Phone: (518) 456-9245 Fax: (518) 456-9287

Student User Profile Request Form


School District: _______________________________________ Phone: (____) ____ - _____

Address: ___________________________ City: _______________________ NY  Zip: _______

Student:(Last) _________________________ (First)______________________ Grade: _____ 

Sponsoring Teacher:______________________________  *Logon Password: _ _ _ _ _ _ _ _ 

(*Please select a password 5-8 alpha/numeric characters in length. )


Specify: [ ] Text based Internet/Pine Email [ ] Continental Internet/Eudora Email

Network Etiquette Guidelines for Students


Userid:  _ _ _ _ _ _ _ _      District Id:  _ _ _ _ _ _ _ _     Date:  ___/___/___

Note:  Student accounts will be purged at the end of the school year. A new form must be submitted yearly.

Statement of Confidentiality

As a student user of Capital Region BOCES E-mail Services, I agree not to:

When there is any indication of unauthorized use or abuse of the system or any other action which interferes with the proper functioning of the system, or impinges on the rights of other users, the New York State Education Department, Capital Region BOCES or other appropriate agency will be authorized to investigate. Unethical or irresponsible use of the system will be referred to the appropriate authorities for disciplinary or legal action. System users have a responsibility to maintain the integrity of the system and to use it only in an authorized and appropriate manner.


Student Signature:________________________________________________  Date: _____________________________


PERSON RESPONSIBLE FOR COMPUTER SERVICES MUST SIGN

Authorized Signature:_____________________________________________  Title: _____________________________


SPONSORING TEACHER MUST SIGN

I agree to sponsor ______________________________________and, while in my class, supervise his/her 
responsible use of the network according to the Statement of Confidentiality guidelines.


Sponsoring Teacher:_______________________________________________  Date: _____________________________


SPONSORING PARENT OR GUARDIAN MUST SIGN

I have read the Statement of Confidentiality and give my permission for an account to be issued  
for my child's use. I certify that the information contained on this form is correct.


Parent Signature:________________________________________________  Home Phone: ( ___ )_________________

Address:___________________________________________ City:_________________________NY  Zip:_____________