Policy Details

5145.15 FORM Directory Information Without Prior Written Consent

5145.15
FORM

STUDENTS

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 included the following kinds of information:

1. Name of student

2. Address

3. Telephone number

4. Major field of study

5. Participation in officially recognized activities and sports

6. Height and weight of members of athletic teams

7. Dates of attendance

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

9. Most recent school attended

10. Date of birth

11. Photograph

12. Videotape not used in a disciplinary manner

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.

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

Litchfield Board of Education

Form adopted: April 19, 2006

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