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JRA-E 3

DENIAL OF CONSENT TO RELEASE STUDENT INFORMATION

FOR SECONDARY STUDENTS

 

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.”  M.S.A.D. 71 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:

 

Principal, Kennebunk High School

89 Fletcher Street

Kennebunk, Maine  04043

 

Text Box: FOR PARENTS OF STUDENTS UNDER THE AGE OF 18:   I request that Kennebunk High School   q                 NOT release the name, address, or telephone number of my son/daughter ____________________________ to any military recruiter or military recruiting organization without my prior written consent.   q                 NOT release the name, address, or telephone number of my son/daughter ____________________________ to any institution of higher learning without my prior written consent.   q                 NOT release information of any kind, including “directory information,” concerning my son/daughter _____________________________ without my prior written consent.   _______________________________________                     _______________________________ Parent/Guardian Signature                                                                 Date   Text Box: FOR STUDENTS 18 YEARS OF AGE OR OLDER:   I request that Kennebunk High School   q                 NOT release my name, address, or telephone number to any military recruiter or military recruiting organization without my prior written consent.   q                 NOT release my name, address, or telephone number to any institution of higher learning without my prior written consent.   q                 NOT release information of any kind concerning me, including “directory information,” without my prior written consent.   _______________________________________                     _______________________________ Student Signature                                                                                Date