HomeMy WebLinkAbout3600F Student Directory Information Opt Out FormSTUDENTS
3600F
Bonneville Joint School District No. 93
(9/17)
STUDENT DIRECTORY INFORMATION OPT OUT FORM
Dear Parent/Guardian:
Under the federal and state law, school districts are required to distribute lists of high school
juniors and seniors (i.e., 17 years and older) with their names, addresses, and telephone numbers to Idaho colleges and universities, United States Armed Forces Recruiting Agencies,
school support organizations, and other authorized agencies, as requested. However, the
Family Educational Rights and Privacy Act and the No Child Left Behind Act mandate that parents/guardians be offered an option to withhold the release of this information each year. If
you wish to withhold the release of your child’s name, address, and telephone number, you must complete the form below and return it to the school. The request to withhold the student information is applicable only to the current school year.
Please return this form to your child’s school.
- - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - REQUEST TO WITHHOLD DIRECTORY INFORMATION
TO: ______________________________________________________ DATE: ___________________
School Name
Student Name: (please print) Date of Birth: Grade:
Address: City: Zip Code:
Telephone Number: Parents’/Guardians’ Names
1. I do not wish to have any directory information of the student named above released to any
individual or organization. (If you check here, DO NOT complete Numbers 2 and 3 below.)
OR
2. I do not wish to release the name, address and telephone number of the student named above to
the agency or agencies I check below.
United States Armed Forces (Military) Recruiting Agencies
Colleges, Universities or Other Institutions of Higher Education
3. I also request to withhold or release the directory information per the boxes I check below:
May Release May Not Release May Release May Not Release
PTO 1. Name
2. Address
Health Department 3. Grade level
4. Date of Birth
Elected Officials 5. Dates of Attendance 6. Parents’/guardians’
names & addresses
________________________________ ________________________________
Signature of Parent/Guardian (if student is under 18) Signature of Student (if student is 18 or older)