Military Opt-Out Form

Required

Parents should be aware that under the “Every Student Succeeds Act,” all military recruiters are entitled to a list of the names, addresses, and telephone numbers of tenth, eleventh, and twelfth graders. We are required under the law to provide these lists to them upon request. Parents may, however, request that their child’s name be removed from these lists by submitting the Military Opt Out form prior to October 1.

Student Namerequired

First Name

Last Name

Student Date of Birthrequired

Must contain a date in MM/DD/YYYY format

Student Email Addressrequired

Parent/Caregiver Namerequired

First Name

Last Name

Federal public law 107-110, section 9528 of the ESEA, “Every Student Succeeds Act” requires school districts to release student names, addresses, and phone numbers to military recruiters upon their request. The law also requires the school district to notify you of your right to opt out from this by requesting that the district not release your information to military recruiters. The completion and return of this form serves as your request to withhold your private information. As a student you have the right to request that your private information is not released to military recruiters and others.

Request to Opt Outrequired

I request that this student’s name, address, and telephone number not be released to Armed Forces and Military Recruiters, or Military Schools.

Student Digital Signaturerequired

First Name

Last Name

Daterequired

Must contain a date in MM/DD/YYYY format

Parent/Caregiver Digital Signaturerequired

First Name

Last Name

Daterequired

Must contain a date in MM/DD/YYYY format

Please complete the security verification below.