School District Superintendent
School District Name & Address

To Whom It May Concern,

I am notifying you that I do not want my personal information or "directory" information on my children released by the school district. I am officially "opting out" of the use of any directory information of my children or my family by the district.

I am also informing you that no information contained on my Declaration of Intent to Provide Home-Based Instruction shall be released to any third party or be used for promotional purposes of the district.

Signed: _________________________