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Denial of Consent to Release Student Information (PVHS)

CODE: JRA-E3

Maine School Administrative District No. 31

DENIAL OF CONSENT TO RELEASE STUDENT INFORMATION

Federal law and regulations pertaining to family educational rights and privacy allow schools, without prior consent, to release at their discretion information from student educational records that has been designated by the school system as “directory information”.  The District has designated the following as directory information: student’s name, participation in officially recognized activities and sports, weight and height of student athletes, grade level in school of participants in extracurricular activities, date of attendance at local school unit schools, and honors and awards received.

In addition, the “No Child Left Behind Act of 2001” contains provisions that require that the school unit provide student names, addresses and telephone numbers to military recruiters and institutions of higher learning when requested to do so, unless the student’s parent/guardian or student 18 years of age or older requests in writing that such information not be released.

If you DO NOT want the information released, please complete the appropriate section of this form and return it to:

                                                                     Superintendent       
                                                                     23 Cross Street       
                                                                     Howland, Maine  04448   

FOR PARENTS OF STUDENTS UNDER THE AGE OF 18:

I request that _____________________________ High School

___________      NOT release the name, address, or telephone number of my son/daughter ______________________ to any military
                         recruiting organization without my prior written consent.

___________     NOT release the name, address, or telephone number of my son/daughter ______________________ to any institution
                        of higher learning without my prior written consent.

___________    NOT release information of any kind, including “directory information,” concerning my son/daughter__________________
                        without my prior written consent.

                                               
Parent/Guardian Signature _____________________________________________       Date________________________________

FOR STUDENTS 18 YEARS OF AGE OR OLDER:

I request that ______________________________ High School

_________    NOT release my name, address, or telephone number to any military recruiter or military recruiting organization without
                    my prior written consent.

_________    NOT release my name, address, or telephone number to any institution of higher learning without my prior written consent

_________    NOT release information of any kind concerning me, including “directory information,” without my prior written consent.

                                               
Student Signature ________________________________________________________     Date_______________