Forms & Policies » Elementary Student Information Disclosure/Publication Form

Elementary Student Information Disclosure/Publication Form

 Notice of Possible Publication of Certain Student Information During the School Year 

 

Dear Student/Parent:

 

Under Massachusetts Department of Elementary and Secondary Education regulations, the school may release for disclosure/publication certain information (called directory information) concerning you/your child from time to time without first obtaining your consent, unless you indicate now that we should not do so. The directory information, which may be released for disclosure/public includes name, address, telephone listing, date and place of birth, dates of attendance, weight and height of members of athletic teams, class, participation in officially recognized activities and sports, degrees, honors and awards.

 

PLEASE FILL OUT THE FORM BELOW AND RETURN IT TO YOUR STUDENT’S SCHOOL ONLY IF YOU DO NOT WANT DIRECTORY INFORMATION SHARED

 

My signature verifies that:

 

£   I DO NOT want my child’s name, picture or video published for school awards or activities. For example, Honor Roll, Science Fair, Sporting events, etc.

 

£   I DO NOT want my child’s directory information (name, address, telephone listing, date and place of birth, dates of attendance, weight and height of members of athletic teams, class, participation in officially recognized activities and sports, degrees, honors and awards) shared with third parties.

 

STUDENT NAME (Print)________________________________________________________________

 

 

STUDENT SIGNATURE_________________________________________________________________

(14 years old and older)

 

 

SCHOOL____________________________________________ GRADE_________ ROOM #________

 

 

PARENT/GUARDIAN NAME (Print)_____________________________________________________

 

 

PARENT/GUARDIAN (SIGNATURE)_____________________________________________________

 

 

Please sign and return to the Principal’s Office

 

 

EVERETT PUBLIC SCHOOLS 121 VINE STREET EVERETT, MA 02149