Jerome Joint School District No. 261

CURRICULUM AND INSTRUCTION 2140F

Student and Family Privacy Rights – Consent Form

The Protection of Pupil Rights Amendment (PPRA), requires the District to notify you and obtain consent or allow

you to opt your child out of participating in certain school activities. These activities include student surveys

analyses, or evaluations that concern one or more of the following areas:

1. Political affiliations or beliefs of the student or student’s parent;

2. Mental or psychological problems of the student or student’s family;

3. Sexuality, including but not limited to sex behavior or attitudes;

4. The student’s sex;

5. Illegal, anti-social, self-incriminating, or demeaning behavior;

6. Critical appraisals of others with whom respondents have close family relationships;

7. Legally recognized privileged relationships, such as with lawyers, doctors, or ministers;

8. Religion, including but not limited to religious practices, affiliations, or beliefs of the student or parents;

9. Individual or family financial information, including but not limited to income;

10. Personal family information.

This requirement also applies to the collection, disclosure, or use of student information for marketing purposes

(“marketing surveys”). The following is a schedule of activities requirement parental notice and consent or opt-out

for the upcoming school year. This list is not exhaustive and, for surveys and activities scheduled after the school

year starts, the District will provide parents, within a reasonable period of time prior to the administration of the

surveys and activities, notification of the surveys and activities and provide them with an opportunity to opt their

child out, as well as an opportunity to review the surveys. (Please note that this notice and consent/opt-out

transfers from parents to any student who is 18 years old or an emancipated minor under State law).

(LIST ALL APPLICABLE SURVEYS AND SCREENINGS TO BE GIVEN IN THE UPCOMING YEAR, THE STUDENTS THEY WILL BE ADMINISTERED TO, THE DATE THEY WILL BE GIVEN, A DESCRIPTION OF THE SURVEY OR SCREENING, AND A STATEMENT OF WHETHER THE SURVEY WILL REQUIRE PARENTAL CONSENT OR WHETHER PARENTS MUST ACTIVELY OPT THEIR CHILD OUT IF THEY DO NOT WISH FOR THEM TO PARTICIPATE.)

If you wish to review any survey instrument or instructional material used in connection with any protected

information or marketing survey, please submit a request to the (DESIGNATED OFFICIAL, SCHOOL ADDRESS). (THE DESIGNATED SCHOOL OFFICIAL) will notify you of the time and place where you may review these materials. You have the right to review a survey and/or instructional materials before the survey is administered to a student.

I _____________________ (parent/guardian’s name) give my consent for ___________________ (student’s name)

to take __________________________________ (survey name) on or about _________________________ (date).

Parent/Guardian’s Signature: ____________________________________________ Date ____________________

Please return this form no later than ______________________ (date) to the following school official:

School Official Name, School Name and Address: ____________________________________________________

Policy History:

Adopted on: 02/25/2021

Revised on: 08/22/2023