Student Information Change- Name, Gender, or Pronouns

Required

Please complete this form if you would like your name and/or pronouns officially changed in both the Mount Greylock Records and the Massachusetts State Department of Elementary and Secondary Education (DESE) Student Information Management System (SIMS).

This form will be submitted to the building Principal and Front Office Staff who manage Student Registrations.

As of this date:required

(Must contain a date in M/D/YYYY format)

the person formerly known as:

First Name, Middle, Last Name

has changed names to:

Updated First, Middle, Last Name

This person now uses the updated name consistently, and that name should be used now on all records.

Preferred Pronouns to use:

Add only if changing

Gender:Select only if changing

Nonbinary

Female

Male

Select only if changing

I attest to this change:required

Student Digital Signature

I attest to this change:required

Parent/Guardian Digital Signature

The relationship between the child and the person executing the statement:required

A copy of this statement will be kept as part of the student record. An indication will also be made on former records to "See record under 'A' after (the date of name change)." Similar notation "See prior record under 'B'" will be included on records under the new name.

Please select the school of current enrollment:required

For reference: Guidance for Massachusetts Public Schools Creating a Safe and Supportive School Environment