Student E-mail Account Application
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 Guidelines for Accessing 4JNet, 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.
Elementary students only require 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 Guidelines for Accessing 4JNet, and I will emphasi e 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: __________________
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