Haverhill Public Schools Media Opt-Out Form 2026-2027
Please fill this form below completely and accurately (once per student per calendar year). See the relevant School Committee Policy, "HPS Social Media Opt-Out Policy", from www.haverhill-ps.org/technology-policies.
Student Information
Only one student per form.
Student Name
*
First Name
Last Name
Current School
*
Please Select
Bradford Elementary School
Bartlett School and Assessment Center
Consentino Middle School
Gateway Academy
Golden Hill Elementary School
Greenleaf Academy
Haverhill High School
CD Hunking School
Moody School
Moody PreSchool Extension
Nettle Middle School
Pentucket Lake Elementary School
Silver Hill Elementary School
Tilton Elementary School
JG Whittier Middle School
Walnut Square Elementary School
Other
Current Grade
*
Please Select
PreK
Kindergarten
01
02
03
04
05
06
07
08
09
10
11
12
Other
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Information
For security and privacy purposes, the information below must match what is on file with your child's school or the request will be rejected.
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
Parent/Guardian Phone Number
*
Format: (000) 000-0000.
Parent/Guardian Signature
By signing this and submitting the form, I agree that all of the above information is factual and I am an authorized representative of the Student referenced.
Submit
Should be Empty: