District Regulations/Exhibits – Jefferson County School District R-1
Book:	District Regulations/Exhibits – Jefferson County School District R-1
Section:	K: School-Community-Home Relations
Title:	Opt Out Form for Disclosure of Personal Information to Military Recruiters, Postsecondary Institutions and Prospective Employers in High Schools
Number:	KLMA-E1
Status:	Active
Legal:
Adopted:	02/12/2007
Last Revised:	05/21/2007
Last Reviewed:

Policy Detail

PARENTS’ AND STUDENTS’ OPT OUT FORM FOR DISCLOSURE OF PERSONAL INFORMATION TO MILITARY RECRUITERS, POSTSECONDARY INSTITUTIONS AND PROSPECTIVE EMPLOYERS IN HIGH SCHOOLS

IMPORTANT NOTICE TO JEFFERSON COUNTY HIGH SCHOOL STUDENTS AND THEIR PARENTS/GUARDIANS ABOUT ACCESS TO STUDENT INFORMATION

According to the Federal No Child Left Behind Act of 2001:

"(1)…each local educational agency receiving assistance under this Act shall provide, on a request made by military recruiters or an institution of higher education, access to secondary school students' names, addresses, and telephone listings.

(2) CONSENT A secondary school student or the parent of the student may request that the student's name, address and telephone listing described in paragraph (1) not be released without prior written consent, and the local education agency or private school shall notify parents of the option to make a request and shall comply with any request." (Section 9528)

Instruction to NOT release student information to recruiters:

The Federal No Child Left Behind Act REQUIRES that the school district provide student names, addresses, and phone numbers to recruiters from the U.S. military and institutions of higher education UNLESS a parent or the student request in writing that this information be withheld.

__________________________________	__________________________________	___________________________
Full Name of Student	Name of School	Grade

As a parent or legal guardian,
___	I request that you DO NOT release the name, address, phone number or school records of the above student to any Armed Forces recruiter or the U.S. Department of Defense.
___	I request that you DO NOT release the name, address, phone number or school records of the above student to any institution of higher education.
___	I request that you DO NOT release the name, address, phone number or school records of the above Student to any prospective employer.
As a student,
___	I request that you DO NOT release my name, address, phone number or school records to any Armed Forces recruiter or the U.S. Department of Defense.
___	I request that you DO NOT release my name, address, phone number or school records to any institution of higher education.
___	I request that you DO NOT release my name, address, phone number or school records to any prospective employer.
_________________________________________________________________________			___________________________
Signature			Date

Jefferson County School District R-1
Jefferson County, Colorado