Request that Directory Information Not Be Released To Recruiters Without Prior Written Consent

Student Name:
Address: State: Zip:
Age: Birthdate: Grade:  
I hereby request that the above-named student's name, address and telephone listing NOT be released without my prior written consent to:
Recruiters from the United States Armed Forces who request such information.
Recruiters from institutions of higher education who request such information.    
I understand by not checking one of the options listed above, that the Board of Education may release, without my prior written consent, the above-named student's name, address,and telephone listing in accordance with Federal and State law. I also understand that if I authorize the release of information to a recruiter from the United States Armed Forces, that such recruiter will be required to sign a form indicating that "any information received by the recruiting officer shall be used solely for the purpose of informing students about military service and shall not be released to any person other than individuals within the recruiting services of the Armed Forces." Finally, I understand that the Board of Education may contact me to seek my consent if specifically requested by a recruiter, but that I am not required to provide such consent.


Signature of Parent/Guardian/Student*____________________________________
                                                         *Student must be eighteen (18) years or older






NEOLA 2005