Data Privacy Request Form
If any parent/guardian would object to having their child’s name, grade, teacher, height and weight –given only if a member of an athletic team, extracurricular participation, or a picture or video taken and used for public distribution or viewing, please fill out and send this request the address above.
Parent/Guardian’s Printed Name:
Address:
City
/ Zip: Phone:
Please keep the above information private with regard to the following student(s):
1. Student’s Name:
2. Student’s Name:
Signature of Parent/Guardian Date
CHECK HERE IF YOU DO NOT WANT INFORMATION RELEASED TO MILITARY ORGANIZATIONS.
Please
note that this request must be filled out each school year and received
by October 15th to be in effect for the current school
year. Thank you.
For District Office Use:
Date Received: ________________
CC: Building: _______ BG:
________ Ken O.: __________
Current School Year:
__________________
Data Privacy Request Form (