The purpose of this document is to create a shared understanding of how the student’s authentic gender will be accounted for and supported at school. School staff, parents/guardians (if appropriate) and the student should work together to develop the document. Ideally, each will spend time completing the sections and then come together to review them and confirm shared agreements. Use the action planning section at the end of the document to track items requiring any follow-up.
School/District: ________________________________________________ Date: _____________________
Name Student Uses: ____________________________ Pronouns Student Uses: ________________________
Name on Birth Certificate: ________________________________________ Sex Assigned at Birth: ________
Date of Birth: ______________________ Student Grade Level: ____________________
Sibling(s)/Grade(s) _______________________ / _________________________ / _____________________
Parent(s) or Guardians(s)/relation to student: _________________________ / ______________________
________________________ / _________________ _________________________ / ________________
Meeting participants: ________________________________, _____________________________________,
____________________________, _____________________________, ____________________________
__________________________________________________________________________
PARENT/GUARDIAN INVOLVEMENT
Parent(s)/Guardian(s) aware of student’s gender status? Yes ____ No ____
Support level: (none) 0 1 2 3 4 5 (high)
If support level is low, what considerations must be accounted for in implementing this plan? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
PRIVACY: CONFIDENTIALITY 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, etc.)
Specify the adult staff members: _____________________, ______________________,
______________________, _______________________, _______________________
Building administration will know (Principal, 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 student: __________________________, ___________________________,
______________________, _______________________, _______________________
Student is open with others (adults and peers) about gender
Other (describe): _________________________________________________________
______________________________________________________________________
If the student has asserted a degree of privacy, what steps will be taken if that privacy is compromised, or is believed to have been compromised?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
How will a teacher/staff member respond to any questions about the student’s gender from:
Other students? ____________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Staff members? ____________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Parents/Guardians/community? _________________________________________________
_________________________________________________________________________
_________________________________________________________________________
STUDENT SAFETY
Who will be the student’s “go to adults” on campus? ____________________, _______________
If these people aren’t available, what should the 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 their need for help:
During class _______________________________________________________________
Outdoors on school property ___________________________________________________
In the halls ________________________________________________________________
Other ____________________________________________________________________
What should the student’s parent(s)/guardian(s) do if they are concerned about how others are treating their child at school? ___________________________________________________
__________________________________________________________________________
Other safety concerns/questions: ________________________________________________
__________________________________________________________________________
PRIVACY: NAMES, PRONOUNS AND STUDENT RECORDS
Name to be used when referring to the student ____________________ Pronouns ___________
Name/gender marker as listed on the student’s identity documents ________________________
Name/gender marker entered into the Student Information System _______________________
Who will be the point person at school for ensuring these adjustments to the student’s records are made and communicated as needed? _______________________________________________
How will the student’s privacy be accounted for and maintained in the following situations or contexts:
Reporting data to the state/other entities __________________________________________
During registration ___________________________________________________________
Completing enrollment _________________________________________________________
Student cumulative file ________________________________________________________
IEPs/Other Services __________________________________________________________
Seating charts/Taking attendance ________________________________________________
With substitute teachers _______________________________________________________
Teacher grade book(s) _________________________________________________________
Standardized tests ___________________________________________________________
School photos _______________________________________________________________
Student ID/library cards _______________________________________________________
Lunch lines/Free lunch card _____________________________________________________
Yearbook ___________________________________________________________________
Assignment of IT accounts/email address ___________________________________________
Distribution of texts or other school supplies ________________________________________
After-school programs _________________________________________________________
Official school-home communication _______________________________________________
Unofficial school-home communication (PTA/other) ____________________________________
Outside district personnel or providers ____________________________________________
Summons to office ____________________________________________________________
PA announcements ____________________________________________________________
Posted lists _________________________________________________________________
How will instances be handled in which the incorrect name or pronoun are used by staff members?
__________________________________________________________________________
__________________________________________________________________________
By students? ________________________________________________________________
__________________________________________________________________________
If the student’s parents/guardians are not aware and/or supportive of the student’s gender status, how will school-home communications be handled, including when individual staff members need to contact parents/guardians? _____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
What are some other ways the school needs to anticipate the student’s privacy being compromised? How will these be handled? ______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
USE OF FACILITIES
Student will use the following bathroom(s) on campus __________________________________
Student will change clothes in the following place(s) ___________________________________
If student/parent/guardian have questions/concerns about facilities, who should they contact?
__________________________________________________________________________
What are the expectations regarding the use of facilities for any class trips? ________________
__________________________________________________________________________
Are there any questions or concerns about the student’s access to facilities? ________________
__________________________________________________________________________
__________________________________________________________________________
EXTRA-CURRICULAR ACTIVITIES
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 in these spaces? ___________________
__________________________________________________________________________
__________________________________________________________________________
Does the student participate in an after-school program? _______________________________
__________________________________________________________________________
__________________________________________________________________________
Are there any other questions or concerns about extra-curricular activities? _________________
__________________________________________________________________________
__________________________________________________________________________
OTHER CONSIDERATIONS
Does the student have any sibling(s) at school? _____ Factors to be considered regarding sibling’s needs? __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Does the school have a dress code? _____ How will this be handled? _______________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Are there lessons, content, traditions or other activities coming up this year to consider (growth and development, social justice units, name projects, school dances, etc.)? __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Are there any specific social dynamics with other students, families or staff members that need to be discussed or accounted for? __________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Does the student use school or district provided transportation? If so, how will the student’s gender be accounted for? _______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
If required to be searched by school staff, what needs to be considered regarding the sex/gender of the staff conducting the search? _______________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
What training(s) will the school engage in to build capacity for working with gender-expansive students? How will the school work to create more gender inclusive conditions for all students?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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Are there any other questions, concerns, or issues to discuss? ___________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
What are specific follow-up or action items emerging from this meeting and who is responsible for them?
NEXT STEPS: SUPPORT PLAN REVIEW AND REVISIOONS
| Action Item | Who? | When? |
How will this plan be monitored over time? __________________________________________
__________________________________________________________________________
__________________________________________________________________________
What will be the process should the student, family, or school wish to revisit any aspect(s) of the plan (or seek additions to the plan)? _______________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Date/Time of next meeting or check-in:
| Date | Time | Location |