Request to withhold directory data/information
Student Name ___________________________________________________________________
Last First Middle
Southern Lakes Consortium Alternative High School has declared the following personally identifiable information contained in a student’s education records as “directory data/information” pursuant to the Family Educational Rights and Privacy Act and state statute 118.125(1)(b) and (2)(j):
Field of study
Participation in officially recognized activities
Dates of attendance
Degree(s) and awards received
Name of the school most recently attended by the student
Directory will be released to any person unless the adult student, parent, or guardian informs the school that all or part of the directory data may not be released without the prior consent of the adult student, parent, or guardian.
Southern Lakes Consortium Alternative High School may not disclose the information as noted below. If you check any or all of the listed directory data items, they will not be given to any person without your prior consent.
______Field of Study
______Participation in officially recognized activities
______Dates of attendance
______Degree(s) and awards received
______Name of the school most recently attended by the student