SAMPLE
XYZ Charter
719 Fourth Street
Anytown, TX
555/555-1234
Release of Directory
Information to
Outside Individuals and
Groups
Directory
information about students in XYZ Charter School may be released to any
individual or organization, (such as an insurance company that files a written
request with the Chief Education Officer or designee). XYZ Charter School does not endorse any
product or service offered by individuals or organizations that have obtained
such list.
Directory
information includes a student’s name, address, telephone number, date, place
of birth,
major field of study,
participation in officially recognized activities and sports, weight and height
of members of athletic teams, dates of attendance, awards received, and the most
recent or previous school attended by a
student.
If
you object to the release of any or all directory information you must notify
the principal in writing within ten days. Your objection will remain in effect unless
you rescind it in writing. If you
have no objection, do not return this form.
Student
Name _____________________________ Current Grade ______________________
Do
not release any directory information about my child to non-school individuals
or
organizations,
but information other than address and phone number can be included in XYZ Charter
School press releases and publications.
Other
(please be very specific)
Parent
Name ________________________________________________________________
Parent
Signature _____________________________________________________________
Date
_______________________________________________________________________
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