Information Release Form - Lausd
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1LOS ANGELES UNIFIED SCHOOL DISTRICT
PARENT/STUDENT HANDBOOK – 2016-2017
INFORMATION RELEASE FORM
Under Federal and State law, school districts may share student directory information with authorized individuals, organizations and/or officials.
Pursuant to California Education Code section 49073, LAUSD has identified the categories of information listed below as directory information
that may be released to the officials and organizations named below. Parents of students 17 years or younger and adult students 18 years
or older may request the school principal limit the release of directory information or not release directory information at all. The request to
withhold the student directory information is applicable only to the current school year.
Additionally, pursuant to California Education Code 69432.9, each grade 12 student will be deemed a Cal Grant applicant, unless the student
is opted out. For seniors who have not opted out, school districts are required to submit their grade point averages (GPAs) to the California
Student Aid Commission (CSAC) for the purpose of determining Cal Grant eligibility and making appropriate financial aid awards for college.
Without the GPA information verified by the school district, CSAC will not be able to determine your child’s eligibility. Seniors who are 18 years
of age or parents/guardians of seniors under 18 years of age may opt out of being automatically deemed a Cal Grant applicant.
PLEASE READ AND COMPLETE THE INFORMATION RELEASE FORM BELOW AND RETURN IT TO YOUR SCHOOL
PRINCIPAL. UNLESS THIS FORM IS RETURNED, YOUR CHILD’S INFORMATION MAY BE RELEASED AS INDICATED.
COMPLETE, SIGN AND RETURN THIS PORTION TO YOUR CHILD’S SCHOOL
LOS ANGELES UNIFIED SCHOOL DISTRICT - 2016-2017 PARENT/STUDENT HANDBOOK
DIRECTORY AND GPA INFORMATION RELEASE FORM
SCHOOL NAME:
DATE:
STUDENT NAME:
Date of Birth:
Grade:
(Please Print)
Address:
City:
Zip Code:
Telephone Number:
1. I do not wish to have any directory information released to any individual or organization.
OR
2. I request to withhold the directory information according to the box(es) I check below:
DO NOT
DO NOT
RELEASE
RELEASE
ELECTED OFFICIALS
1. Name
L.A.COUNTY DEPT OF CHILD AND FAMILY SERVICES
2. Address
L.A.COUNTY DEPT OF HEALTH RELATED SERVICES
3. Date of Birth
L.A.COUNTY DEPT OF MENTAL HEALTH
4. Dates of Attendance (e.g. academic year or semester)
L.A.COUNTY DEPT OF PROBATION
5. Current and most recent previous school(s)
LAUSD SCHOOL-BASED HEALTH CARE PROVIDERS
6. Degrees, honors, and awards received
LA TRUST FOR CHILDREN’S HEALTH
PARENT TEACHER STUDENT ASSOCIATION
3.
For 11
th
and 12
th
grade students only: I do not wish to release the name, address, and telephone number of the
student named above to the agency or agencies I check below.
_____ United States Armed Forces (Military) Recruiting Agencies
_____ Colleges, Universities or Other Institutions of Higher Education
_____ National Student Clearinghouse (to track college attendance)
4.
For 12
grade students only:
th
____
I do not want the GPA of the student named above submitted to the California Student Aid Commission.
Signature of Parent/Guardian (if student is under 18)
Signature of Student (if student is 18 or older)
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