Middle-High School Publishing Student Information Form 21-22

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Dear Parent/Guardian:
The Bloomfield Central School District actively purses ways to celebrate the accomplishments of our students and staff. As part of this effort, lists of student names, pictures of students, and/or articles citing individual student accomplishments are published in newsletters, area newspapers, and/or in electronic form on our district website and/or social media sites (Facebook, twitter, Instagram) If you have a concern about any of the information listed below appearing in any of these publications, please fill out the appropriate selections by September 15, 2021 This form will need to be updated yearly. If you would like to make a change mid-year, please contact the High School or Middle School Office.

Student Last Name *

Student First Name *

Grade Level *

Please note- the elementary form is different. This form is only for grades 6-12.

Please DO NOT publish my child's (check all that apply)

Address and/or phone number to other class members

Name

Picture

Grade level

Participation in Sports, Clubs, Performing Groups

Honors, degress, and awards

Name of Educational Institution Previously Attended

Other:

Typing your name in the box constitutes your electronic signature. Submission of this form is automatically time and date stamped. *

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