REPORT OF STUDENT DISCLOSURE OF IDENTITY
Dear (Parent/Guardian) _________________,
This letter is to inform you that your student (student’s name listed on registration) ________________
has made a request of a licensed employee to (check all that apply):
______ make an accommodation that is intended to affirm the student’s gender identity as follows:
______________________________________________________________________________
______use a name, pronoun or gender identity that is different from the name, pronoun and/or gender
identity listed on the student’s school registration forms. The name, pronoun, or gender identity
requested is ________________________________________________________________________.
If you would like to amend the student’s registration paperwork to permit the student’s requested
accommodation and/or include the use of the above-referenced name/pronoun/gender identity, please
complete the attached form and return it to the district administration office.
Sincerely,
____________________________________________ __________________
Administrator Date
