(Not to be filed if the parent/student has no objection)
I, the undersigned, being a parent of a student, or a student eighteen (18) years of age or older, hereby note my objection to the disclosure or publication by the Pulaski County Special School District of directory information, as defined in Policy No. 4.13 (Privacy of Students’ Records), concerning the student named below. The district is required to continue to honor any signed opt-out form for any student no longer in attendance at the district.
I understand that the participation by the below-named student in any interscholastic activity, including athletics and school clubs, may make the publication of some directory information unavoidable, and the publication of such information in other forms, such as telephone directories, church directories, etc., is not within the control of the District.
I understand that this form must be filed with the office of the appropriate building principal within ten (10) school days from the beginning of the current school year or the date the student is enrolled for school in order for the District to be bound by this objection. Failure to file this form within that time is a specific grant of permission to publish such information.
I object and wish to deny the disclosure or publication of directory information as follows:
Deny disclosure to military recruiters ____
Deny disclosure to Institutions of postsecondary education ____
Deny disclosure to Potential employers ____
Deny disclosure to all public and school sources ____
Selecting this option will prohibit the release of directory information to the three categories listed above along with all other public sources (such as newspapers), AND result in the student’s directory information not being included in the school’s yearbook and other school publications.
Deny disclosure to all public sources ____
Selecting this option will prohibit the release of directory information to the first three categories listed above along with all other public sources (such as newspapers), but permit the student’s directory information to be included in the school’s yearbook and other school publications.
Name of student (Printed)
Signature of parent (or student, if 18 or older)
Date form was filed (To be filled in by office personnel)
Date Adopted: 8/11/15
Manual Adoption: 2/8/00