5145.15  Form 3

DENIAL OF PERMISSION TO RELEASE CERTAIN

DIRECTORY INFORMATION WITHOUT PRIOR WRITTEN CONSENT

Dear Parent/ Guardian:

Certain directory information may be released to media, colleges, civic or school related organizations and state or governmental agencies including military recruiters, as well as published programs for the athletic, music and theater presentations of this school district.

Directory information includes the following kinds of information:

1.  Name of student

2.  Address of student

3.  Telephone number

4.  E-mail address of student

5.  Major field(s) of study

6.  Participation in officially recognized activities and sports

7.  Height and weight of members of athletic teams

8.  Dates of attendance

9.  Degrees and awards received, including publication of honor roll

10.  Most recent school attended

11.  Date of birth, place of birth

12.  Photographic, computer and/or video images

13.  Videotape not used in a disciplinary manner

14.  Parent's name/e-mail address

Please circle the specific categories of information, if any, listed above that you do not wish to be released without your specific prior written permission.

_____The release of all Directory Information is denied.

Please be advised that the right to opt out of directory information does not include the right to refuse to wear, or otherwise disclose, a student identification (ID) card or badge.

This form must be completed and returned to the school principal within ten (10) days after publication of the notice on "Directory Information."

_______________________________                                 ____________________________________                                ________________
Name of Student                                                                                                School                                                                              Grade

________________________________                               ____________________________________
Parent's Signature                                                                                                 Date