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3233 Form - Request to Prevent Disclosure of Directory Information

FORM - REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION

WWPS Procedure 3233 – Under the Family Educational Rights and Privacy Act, the following information is considered “directory information” and may be released to anyone, including the media, colleges and universities, and the military.

To prevent release of this information, you must inform Walla Walla Public Schools using this form that you do not want this information released. “Directory information” includes: student’s name, address, age, birthplace, participation in officially recognized school events and programs, weight of athletic team members, awards, diplomas, photographs, and student work – both print and electronic such as school publications and web sites.

Under the No Child Left Behind Act of 2001, 20 U.S.C. § 9528, the military is entitled to request the names, telephone numbers and addresses of students unless the parent, guardian or eligible student requests that such information not be provided.

You have the right under the above laws to choose whether your student’s information is released or not. Parents and eligible students considering withholding disclosure of directory information should evaluate the consequences of such a decision carefully.

The request to prevent disclosure of directory information will be honored for the current school year unless specifically revoked in writing. Continuing students must complete a new non-disclosure form each school year. Submission of this form will not affect directory information already published or released.

Please check the appropriate choice below.

__  I DO NOT consent to the release of the above directory information about the student named below, except as authorized by law.

__  I consent to the release of the above directory information about the student named below, except information about this student MAY NOT be released to the military.

Students’ Name:                                                                                       Student ID#:                                                                                                               

Parent/Guardian’s Name:                                                                                                                                              

Home Address:                                                                                                                                              

City, State, Zip Code:                                                                                                                                              

Home Phone:                                                                                                                                              

Parent/Guardian/Eligible Student’s Signature:                                                                                                                                              

Date:                                                                                                                                              

Please return completed form to student’s school principal.

Revised: April 2016

WALLA WALLA PUBLIC SCHOOLS • 364 South Park St. • Walla Walla, WA 99362 • Phone: 509-527-3000 • Fax: 509.529.7713

SS-logo-alert-transparent Safe Schools Tip Line: 855.976.8772