THE SCHOOL DISTRICT OF PALM BEACH COUNTY

Contract/Agreement AddendumConcerning Student Information

ADDENDUM, Concerning Student Information, to the ContracUAgreement ("the Contract") dated,between the school (named below) or The School Board of Palm Beach County, Florida (named be/ow) and vendor partner(named below).

School or School Board The School Board of Palm Beach County

Vendor or PartnerPursuant to School Board Policy 5.50, receipt of which is acknowledged by the vendor's/partner's signature below, The SchoolBoard of Palm Beach County, Florida (the "School Board") hereby designates [vendor/partner] ("the Party") as an "otherschool official" for the purpose of receiving limited personally-identifiable student information under section 1002.22(3)(d)2,Florida Statutes, because the School Board recognizes the Party has a legitimate educational interest in receiving thisinformation in order to carry out the Party's responsibilities for the school or School Board under the Contract. (All other termsof the Contract remain the same.)

Scott F. Meier, D.D.S., P.A.

As a condition precedent to receiving confidential student information, the Party warrants and agrees that the Party:

• will limit the use of, or access to, confidential student information to the limited scope of information actually needed tocomplete the Party's duties and/or services under the Contract. The School Board has determined that the Party has alegitimate educational interest in receiving only the following fields of student data, for example: name, grade-level, schoolattending, etc. (Indicate fields of data requesting below); andname, grade, school attending, program of study, and age

• will limit the access to student information to its employees and/or agents who actually have a legitimate educationalinterest in the information (i.e., they legitimately need to access the information in order to carry out the Party'sresponsibilities under the Contract); and

• shall avoid, and shall instruct applicable employees/agents to avoid, accessing personally-identifiable student information,except for the legitimate purposes recognized under this Addendum, and shall require that all employees/agents accessingthe data must be trained in, and sign an acknowledgement regarding, the confidentiality requirements; and

• will comply with the requirements of Fla. Admin. Code Rule 6A-1.0955(6)(g), that student information shall not be disclosedby the Party in any form to any party other than appropriate other school officials or the Party's employees/agents to theextent allowed herein (even if the document is first redacted to remove personally-identifiable information), without the priorwritten consent of the adult student or the minor child's parenUguardian, as appropriate; and

• shall maintain any confidential student information in secure data processing facilities or in securely locked cabinets, andthe Party shall monitor the security and safekeeping of the confidential data; and

• will dispose of all information disclosed to it by the school or the School Board (and any copies thereof), after the purposefor which the information is disclosed has been served, or five years after the receipt of the information (whichever issooner), by shredding paper documents finely enough to prevent possible recovery of information, and by totally erasingand over-writing (or physically destroying) any electronic media such as computer files, tapes, or diskettes, or physicallydestroyed.

The parties acknowledge that the terms contained in this Addendum supersede any inconsistent terms in the Contract.

IN WITNESS WHEREOF, the parties hereto have executed this Addendum:

Legal name of the Party (vendor/partner) The School

Date Signature of person having authority Dateto enter legally binding agreementson behalf of the School or The School Board ofPalm Beach County, Florida

The School Board of Palm Beach Countyor The School Board of Palm Beach County, Florida

PBSD 2220 (New 9/8/2006) ORIGINAL - attach to contract Exhibit # A

HiE SCHOOL DISTRICT OF PAI-M SEACH COUNTY

Beneficial Interest and Disclosure of Ownership Affidavit

Bid No. ~_ Project No.1Title

Corporate Name \.. :If (\~ J:J (,()) \hI' (\(l\ Tax FEIN No. _

Before me, the undersigned authority, personally appeared, ~ ('...\1.\-\- \ I\. l' \ C RJ ' ("CorporateRepresentative") this day of , 200 ~ who, first being duly sworn, as required by law,subject to the penalties prescribed for perjury, deposes and says:

1) Corporate Representative has read the contents of this Affidavit, has actual knowledge of the facts containedherein, and states that the facts contained herein are true, correct, and complete.

2) The fOllowing is a list of every "person" (as defined in Section 1,01 (3), Florida Statues to include individuals.children firms. associates, joint adventures, partnerships, estates, trusts, business trusts. syndicates.fiduciaries, corporations and all other groups and combinations) holding 5% or more of the beneficial interestin tile disclosing entity: (If more space is needed, attach separate sheet)

A. Persons or corporate entities owning 5% or more:Name

1..::.)(, i '\\ ~(\t: \ n?Address

r)l)tl \ h\ \" n "\... T ,hi r\ ~u,;)e 117Pet.centa~

1C,L;/,5

B. Persons or corporate entities who hold by proxy the voting power of 5% or more:

Name Address Percentage

C. Stock held for others and for whom held:

1. Name 12. From Whom Held Address Percentage

1.2.----------------~---------------------------------4~--------1; ~ _1-----------------------------------~------2. ~----------------------------------_+---------1. ~------------------------------------_+---------2. __ ~ ~ ~~-------------L----------

day of--' ,. ,201'-0. by_____________________ --"Such person(s) (Notary ublic must check applicable box).D is/are personally known to me. Dproduced a current driver license(s). 0 produced as identification.

(NOTARY PUBLIC SEAL) 7Z~ ~~ ~Nota~iC -.:::z:

A/-W)4 ;fk f b ,Jt2 /ed8/[/

SWORN TO and subscribed before me this

PBSD 1997 (Rev. 1/13/2009)

NOTARYPUBLIC· STATE OF flORIDA",lit, Nl"~:'- eva Ruth Jordan\~}Co~ssion #DD629676-"'/il\"" Expires: MAR. 02, 2011

BONDED THRU ATLANTIC BONDING CO.,INC.

(Print, Type or Stamp Name of Notary Public)