JRA-E-1 Denial of Consent to Release Student Information

DENIAL OF CONSENT TO RELEASE STUDENT INFORMATION

Federal law and regulations pertaining to family educational rights and privacy allow schools, without prior consent, to release at their discretion information from student educational records that has been designated by the school system as “directory information.” The South Portland School Department has designated the following as directory information: student’s name, participation in officially recognized activities and sports, weight and height of student athletes, grade level in school of participants in extracurricular activities, date of attendance at local school unit schools, and honors and awards received.

In addition, the “No Child Left Behind Act of 2001” contains provisions that require that the school unit provide student names, addresses and telephone numbers to military recruiters and institutions of higher learning when requested to do so, unless the student’s parent/guardian or student 18 years of age or older requests in writing that such information not be released.

If you DO NOT want the information released, please complete the appropriate section of this form and return it to: Superintendent or Principal (name) .

FOR PARENTS OF STUDENTS UNDER THE AGE OF 18:

I request that South Portland High School

NOT release information of any kind, including “directory information” (see above), concerning my son/daughter without my prior written consent. (This will restrict including the student in honor roll lists, officially recognized athletic and activity programs, graduation programs, and yearbooks.)

NOT release the name, address, or telephone number of my son/daughter to any military recruiter or military recruiting organization without my prior written consent.

NOT release the name, address, or telephone number of my son/daughter to any institution of higher learning without my prior written consent.

Parent/Guardian Signature Date

FOR STUDENTS 18 YEARS OF AGE OR OLDER:

I request that South Portland High School

NOT release information of any kind concerning me, including “directory information” (see above), without my prior written consent. (This will restrict including the student in honor roll lists, officially recognized athletic and activity programs, graduation programs, and yearbooks.)

NOT release my name, address, or telephone number to any military recruiter or military recruiting organization without my prior written consent.

NOT release my name, address, or telephone number to any institution of higher learning without my prior written consent.

Student Signature Date

Revised: 1.04.12

AttachmentSize
JRA-E-1 Denial of Consent to Release Student Information-1.pdf50.23 KB