regarding the
RELEASE OF NAME, ADDRESS, AND TELEPHONE NUMBER

School ______________________________________ Date ________________

Student Name_________________________________ Date of Birth _________

As a student you have the right to request that your private information is not released to military recruiters and others. Complete this Opt-Out form and give it to your Principal or School Administrator.

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

Signature of parent or guardian ______________________________

or

____ I am 18 years old and request my own name, address, telephone number and school records not be released to the Armed Forces, Military Recruiters, or Military Schools.

Signature of student______________________________

Date:___________________

Federal public law 107-110, section 9528 of the ESEA, "No Child Left Behind Act" requires school districts to release student names, addresses, and phone numbers to military recruiters upon their request. Students are then called at home by recruiters and pressured to join the military. 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.

from www.militaryfreezone.org