Date: May 18,
Student Name ____________________________________________
Student ID #___________________________________________________
Grade ________ Homeroom __________________________
For annual notices on Directory Information, Student Records, Military Recruiting and Protection of Student
Rights, please see the District Parent and Student Handbook.
*Under federal law and school policy, the school district may release the following information without prior parental
consent: Student name, participation in officially recognized activities and sports, weight and height of members of
athletic teams, degrees, honors, and awards received, major field of study, dates of attendance and the most recent
school attended. If you do not want this information released, please contact your school to submit a written
request. This form must be completed each year [Non-Release of Student Directory Information Form].
*Student photographs are commonly used in yearbooks, newsletters, websites and other school-related publications.
If you do not want your student’s photograph used or released for these purposes or for news media, please
contact your school to submit a written request [Publicity Denial and Non-Release of information to School
*Many schools or PTAs publish school directories that include parent/guardian contact information. If you do not
want your name and contact information released for the school directory, please contact your school to submit
a written request [Publicity Denial and Non-Release of information to School Directory Form].
*If you do not want your student to have access to district-provided email or on-line educational tools including
Google Apps for Education (an online collaboration suite used to increase collaboration between students and
teachers while providing access to a rich toolset for learning), please contact your school.
HIGH SCHOOL ONLY
129. I do not want my child’s name, address and phone number released to:
Military Recruiters College Recruiters
The Every Student Succeeds Act requires school districts to provide, upon request, the names, addresses and
phone numbers of high school juniors and seniors to military recruiters, colleges and universities. If you do not
want the school district to provide information about your student to either the military or colleges and
universities, you have the opportunity to “opt out.” In order to do so, you must check one or both of the
By signing this form, I agree that all the information is true. If it is determined that the address I have
provided is false, I acknowledge that my student could be removed from the school immediately.
130. Signature of Parent/Responsible Adult (Required) ________________________________ Date ____________________
131. Signature of Parent/Responsible Adult __________________________________________ Date ____________________
Portland Public Schools wishes you and your student a successful academic school year!
Portland Public Schools recognizes the diversity and worth of all individuals and groups and their roles in society. It is the policy of
the Portland Public Schools Board of Education that there will be no discrimination or harassment of individuals or groups on the
grounds of age, color, creed, disability, marital status, national origin, race, religion, sex or sexual orientation in any educational
programs, activities or employment.