Request to Withhold Directory Information

Please fill out this form, sign and:

Return to:

I hereby request District 106 to withhold student directory information which includes:

1. Name
2. Address (local, permanent, and electronic mail)
3. Telephone numbers
4. Grade
5. Home Room
6. Student activities
7. Weight/height (athletic teams)
8. Date(s) of attendance
9. Enrollment status (enrolled or not enrolled)
10. Date of graduation
11. Awards received and where received

Filing this form will preclude District 106 from releasing directory information to anyone without express written consent. To process this request you must present this form along with photo identification to any school office or mail this form along with a copy of photo identification to the address listed above.

I have read this form carefully and understand the consequences of my decision to prevent release directory information. I understand:

• This prohibits District 106 from acknowledging any information regarding student enrollment to any third party unless a written request with my signature is received. No information will be released to me or any person(s) via the telephone or email.
• This does not prevent disclosure to personnel within District 106, parties designated as school officials under FERPA, or other exceptions detailed in the District 106 Notification of Parent and Eligible Student Rights Under FERPA, or a lawfully issued subpoena.
• This suppresses my information verbally and in printed form including excluding student name/address from future printed telephone directories and other similar printed material, such as commencement programs, athletic rosters, yearbooks, and other official public documents created by District 106.
• This request will remain in place for the current and future school years. If I ever want to remove this withholding request, I must complete a "Release Directory Information" request and provide photo identification.

Today's Date: _____________________________________

Student Name: _____________________________________

Parent/Guardian Name: _____________________________________

Parent/Guardian Email: _____________________________________

Please review your entries on this form. If all of the information is entered correctly please sign and submit the form to the address at the top of the form.

Signature: _____________________________________ Date: ___________________

Office Use Only

Received By: ____________________________________Date Received: ___________________

Revised 2/20/2018