Litchfield Public Schools
35 Plumb Hill Road ~ P.O. Box 110 ~ Litchfield, Connecticut ~ 06759-0110
STUDENTS # 5145.15
DENIAL OF PERMISSION TO RELEASE CERTAIN
DIRECTORY INFORMATION WITHOUT PRIOR WRITTEN CONSENT
Dear Parent or 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:
- Name of student
- Telephone number
- Major field of study
- Participation in officially recognized activities and sports
- Height and weight of members of athletic teams
- Dates of attendance
- Degrees and awards received, including publication of honor roll
- Most recent school attended
- Date of birth
- 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 StudentSchoolGrade
Litchfield Board of Education
Form Adopted: 4/19/2006