To: All Parents
School Year: ___________
The items listed below are designated as “directory information” of [name of agency or school] and may be released for any purpose at the discretion of [name of agency or school]. [Cite state laws and regulations or local policies, where applicable.] Under the provisions of the Family Educational Rights and Privacy Act of 1974, as amended, you have the right to withhold the release of any or all of the information listed below.
[Listed below are examples of directory information]
Name of student
Address of student
Telephone number of student
Electronic mail address
Date and place of birth
Dates of attendance
Participation in officially recognized activities and sports
Weight and height of members of athletic teams
Please consider very carefully your decision to withhold any item of “directory information.” Should you decide to inform [name of agency or school] not to release any or all of the items listed above, any future requests for such information from individuals or entities not affiliated with the [name of agency or school] will be refused. Please indicate here your request to withhold any or all of the above items:
If this form is not received in [name of office] prior to [date], it will be assumed that the above information may be released for the remainder of the current school year. A new form for nonrelease must be completed each [term/semester/year].
Parent’s Name: ________________________
Student’s Name: ________________________