Parent Consent Form for No Child Left Behind Act

September 22, 2003

PARENT CONSENT FORM

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RELEASE of STUDENT 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.  You do not have to participate in this program.

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

_________            DO NOT DISCLOSE my child's contact information without my prior permission.

or

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

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

______Colleges and other educational institutions

______Prospective employers 

or

_________            I authorize ________________ School to disclose my child's 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 child's name and contact information will not be released.

NAME [please print] ____________________________________     

Student's Name [please print]_____________________________

Signature_____________________________________________

Date _________________________________________________

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