5145.14 Form 1

_____________________PUBLIC SCHOOLS

_____________________________, Connecticut

   Access to Student Information by Military and/or College Recruiters

Name of Student: _____________________________  Date: ______________________

Name of Parent: ______________________________  School: ____________________

Dear Parent/Guardian and Secondary Students:

Our District receives funds from the federal government under the Every Student Succeeds Act of 2015.  These funds are used in a variety of ways to provide additional help to students in greatest academic need.  The law also requires that districts receiving these funds must, upon request, provide to military recruiters, colleges and universities, access to the names, addresses and telephone listings of secondary students.

It is important for you to know that a secondary school student eighteen (18) years of age or older, or his/her parent or guardian may request that the student's name, address, and telephone number not be released by the District without prior written parental consent. If you would like to make such a request, please complete the following and return it to your child's school.

______________________________________________________________________________________

Parent or Guardian: Please complete this section and return the entire form to your child's school. Use a separate form for each child.

I am aware the District must provide access to military recruiters and colleges or universities of student names, addresses and telephone listings.  I am aware the District will provide this information upon request, unless I require that such information not be given to the following groups without prior written parental consent:

Military Recruiters (please check one)

[ ]  Do not release my secondary student's information to military recruiters until you have first obtained my prior written parental consent before doing so.

[ ]  I am a student eighteen years of age or older and do not want my information released to military recruiters until you have first obtained my prior written consent before doing so.

Colleges, Universities, or Institutions of Higher Learning (please check one)

[ ]  I am a student eighteen years of age or older and do not want my information released to colleges, universities or other institutions of higher learning until you have first obtained my prior written parental consent before doing so.

[ ]  Do not release my secondary student's information to colleges, universities or institutions of higher learning until you have first obtained my prior written parental consent before doing so.

Parent Signature: ____________________________________  Date: _______________

Adult Student Signature: _______________________________  Date: _______________