Directory Information Opt Out Form printable pdf download

Directory Information Opt Out Form

CLEVELAND METROPOLITAN SCHOOL DISTRICT

DIRECTORY INFORMATION OPT OUT

Directory information includes student’s name, address, telephone number(s), date and

place of birth, participation in officially recognized activities and sports, achievement

awards or honors, student’s weight and height, if a member of an athletic team, major

field of study, dates of attendance and date of graduation.

Directory information will be released to anyone without a parent’s written consent

unless this form is completed and returned to your child’s school.

CHECK ONLY ONE BOX BELOW

NO RELEASE TO ANYONE.

I DO NOT want directory information about my child released to anyone

without my written consent. I acknowledge that this will prevent the

automatic release of directory information to college, military or

scholarship institutions.

NO RELEASE TO MILITARY RECRUITERS ONLY.

I DO NOT want directory information about my child released to military

recruiters without my written consent.

PLEASE WRITE LEGIBLY

Pupil Name(s)

________________________________________________

Student ID(s)

________________________________________________

Grade(s)

________________________________________________

School(s)

________________________________________________

Home Address

________________________________________________

Phone Number

________________________________________________

Parent/Guardian Signature

________________________________________________

Print Name

_____________________________DATE_____________

 If both boxes are checked above, we will not release directory information to

anyone except by your consent, court order or subpoena.

 If no box is checked above, you need not return this form and we will release

directory information to anyone requesting it.

RETURN THS FORM TO YOUR CHILD’S SCHOOL!

School secretaries will input this information into student information system

and place this hardcopy into each named student’s permanent file.

Directory Information Opt Out Form