OPT-OUT FORM PROHIBITING SCHOOL OFFICIALS FROM
RELEASING YOUR NAME, ADDRESS AND TELEPHONE
NUMBER TO MILITARY RECRUITERS

School _______________________________________________

Date ____________________

Student Name _________________________________________

Date of Birth ____________________

Dear _________________________________________________

(Name of School)

I understand that the No Child Left Behind Act of 2001 allows a
student or a student’s parent the right to prohibit a school from
providing the military with a student’s personal information.

_____ I request that this student’s name, address, and telephone
number not be released to Armed Forces, 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 _____________________________________

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. The military uses this information to recruit students.
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.