Opt Out Form For 2014-2015
Tuesday, September 16, 2014 at 09:59AM STUDENT PRIVACY PROTECTION OPT-OUT REQUEST
PLEASE TAKE NOTICE that in accordance with the fundamental constitutional rights of parents and legal guardians to determine and direct the care, teaching and education of their children, and the relevant state and federal statutes, I hereby request my child ______________________________ be exempted and excused for the school year _______________ from the following check marked activities:
__Any and all standardized testing or activities required by law, under which individual student data are collected and/or shared with the federal government or other entities outside of the local school district; or are used for the purposes of school, student, or teacher accountability, including but not by way of limitation to, academic, achievement and annual tests, state-wide performance assessments and Common Core State Standards aligned assessments and pilots. Any and all tests, assessments, or surveys not limited solely to proficiency in core academic subjects. This includes:__________________________________________
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__Any and all tests, assessments, or surveys used to measure pupils’ values, attitudes or beliefs.
__Any survey, analysis, or evaluation that reveals information concerning my child, myself or other members of my family related to: (1) political affiliations or beliefs of the student or the student’s parent; (2) mental or psychological problems of the student or the student’s family; (3) sex behavior or attitudes; (4) illegal, anti-social, self-incriminating, or demeaning behavior; (5) critical appraisals of other individuals with whom respondents have close family relationships; (6) legally recognized privileged or analogous relationships, such as those of lawyers, physicians, and ministers; (7) religious practices, affiliations, or beliefs of the student or student’s parent; or (8) income.
__The collection, tracking, housing, reporting, selling, or sharing with any party outside of the local school district, of non-educational related information on my child or my family, including, but not limited to: religion, political affiliations, biometric data, psychometric data, and medical information. Biometric data includes fingerprints, retina and iris (eye) patterns, voiceprint, DNA sequence, facial characteristics, handwriting, and any other unique physical identifying traits. Psychometric data includes, but is not limited to: personality traits, attitudes, abilities, aptitude, social and emotional development, tendencies, inclinations, interests, and motivations.
__The sharing with any party outside of the local school district of my child’s directory information, including, but not limited to: name, address, telephone listing, e-mail address, photograph, date and place of birth, major field of study, grade level, enrollment status, dates of attendance, participation in officially recognized activities and sports, weight, height, athletic teams, degrees, honors, awards, and most recent educational agency or institution attended.
__The sharing with any party outside of the local school district of my child’s student ID number, social security number, or other unique identifying number.
__Any computer or online based educational services activities or assessments through which individual student data or metadata is stored in a manner inconsistent with industry requirements and best practices or is shared with any party outside the local school district.
__Any Common Core State Standards aligned activities, surveys or assessments that concern the attitudes, beliefs, including religious or political beliefs, or value systems of individual students.
This executed form supersedes all prior Opt-Out forms. ______________________ Grade _________
Date_______________Phone # __________________________E-Mail_________________________________________
Parent/Guardian’s Name(s)_________________________________________________________
Signature_____________________________________________________________________
Received by (name) ____________________________________________________________
Signature________________________________________ Date received________________