ILD-R
PROTECTION OF PUPIL RIGHTS AMENDMENT – SUPPORTING FORMS
Protection of Pupil Rights Amendment - Consent For Specific Activities
(For activities not funded in whole or in part by the United States Department of Education)
Dear Parent/Guardian,
For your convenience you will find attached a copy of our school district’s “Notification of 
Protection of Pupil Rights Amendment” (PPRA).  On ________________________ at 
                    Date
_________________________________ there will be a survey, analysis, or evaluation, and 
Name of School/Site
your consent is required so that your child(ren) may participate. This activity consists of:
 Description:  _________________________________________________________________
____________________________________________________________________________
Please sign below in the event that you consent to your child(ren)’s participation and return this 
form to your Principal/designee by _________________________________________.
Five (5) days before activity or as directed
If you would like to review any survey instrument or instructional material used in connection 
with any protected information or marketing survey, please submit a request to your 
Principal/designee. You will be notified of the time and place where you may review these 
materials. You may review a survey and/or instructional materials before the survey is 
administered to a student.
As the parent/guardian, I give my consent for my child(ren), as noted below, to participate in 
the activity designated above.
STUDENT (PRINT NAME)                SCHOOL                                  GRADE
_________________________           ____________________                    _______
_________________________           ____________________                    _______
_______________________________________________    ________________________
                      Parent Signature                                                                         Date
Opt-Out For Specific Activities
(For activities not funded in whole or in part by the United States Department of Education)
Dear Parent/Guardian,
For your convenience you will find attached a copy of our school district’s “Notification of 
Protection of Pupil Rights Amendment” (PPRA).  On ________________________ at 
                    Date
_______________________________ there will be a protected information survey conducted.
Name of School/Site
This activity consists of: _____________________________________________________
______________________________________________________________________
If you do not want your child(ren) to participate, please sign below and return the form to your 
Principal/designee by _______________________________________________________.
Five (5) days before activity or as directed
OPTIONAL: You may also opt out of the activity by calling or e-mailing your Principal no later than _____________________________________ at _______________________ or
 Five (5) days before activity or as directed                        Phone
             _____________________________________. 
  e-mail address
If you do not indicate your decision to opt out by the date set forth above, the student will be 
permitted to participate in the activity.  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 your Principal/designee. You will be notified of the time and place 
where you may review these materials. You may review a survey and/or instructional materials 
before the survey is administered to a student.
As the parent/guardian, I do not want my child(ren), as noted below, to participate in the 
activity designated above and, by signing and returning this form, indicate my decision to opt 
them out of the activity.
STUDENT (PRINT NAME)               SCHOOL                                          GRADE
_______________________           ____________________                    _______
_______________________           ____________________                    _______
_______________________________________________          ________________________
                      Parent Signature                                                                         Date