Policy Details

5145.15 FORM 2 Notification to Caregivers RE Release of Certain Information



Litchfield Public Schools

35 Plumb Hill Road ~ P.O. Box 110 ~ Litchfield, Connecticut ~ 06759-0110


Release of Certain Information
Under the "No Child Left Behind Act"


Dear Caregiver:

Pursuant to the federal "No Child Left Behind Act," P.L. 107-110 (Title Ix, Sec. 9528), the Litchfield Public School District must disclose to military recruiters and institutions of higher learning, upon request, the names, addresses and telephone numbers of high school students.

The district must also notify parents/guardians of their right and the right of their child to request that the District not release such information without prior written consent.

Caregivers wishing to exercise their option to withhold their consent to the release of the above information to military recruiters and institutions of higher learning must sign this form below and return it to the Building Principal by ___________________.


Reservation of Consent for the Release of Certain Student

Information under the "No Child Left Behind Act"

Please do not release the name, address and telephone number of

Name of Student

to military recruiters and institutions of higher learning.


Print Name of StudentSchoolGrade


Parent's/Guardian's SignatureDate

Litchfield Board of Education
Form Adopted: 4/19/2006
Form Revised:9/10/2020

Download a PDF of this FORM