Student Consent Form for No Child Left Behind Act

STUDENT CONSENT FORM
For
RELEASE of NAME, ADDRESS and PHONE NUMBER

Our school may be requested to provide the names and addresses of high school students to military recruiters, colleges and other groups.

As a student you have the right to request that the information not be released without prior written consent from your parents or from you if you are 18 or older.

Please check below to indicate whether you wish to have your name, address and telephone number disclosed to the groups that may request it.

_________ DO NOT DISCLOSE my contact information without prior permission.

or

_________ DO NOT DISCLOSE my name, address and telephone number to the entities checked below without prior permission:

______US military (Army, Navy, Air Force, Marines, etc.)

______Colleges and other educational institutions

______Prospective employers

or

_________ I authorize ________________ School to disclose my name, address and phone number as part of the school directory.

Your decision not to return the form will be taken as an instruction to __________ High School not to release the requested information and your name and contact information will not be released.

NAME [please print] ____________________________________

Signature_____________________________________________

Date _________________________________________________

Check here if you are over 18 [ ]