Form No. OGC-S-2016-07
Office of the General Counsel
OGC-S-2016-07– Request To Opt Out Of Directory Information
Approved 6.22.16
Page 1 of 1
Standard Form Approved
by the Lone Star College
Office of the General Counsel
Request to Opt Out of Directory Information
To: All Students
These items listed below are designated as directory information and may be released for any purpose at the
discretion of the College.
Under the provisions of the Family Educational Rights and Privacy Act of1974, as Amended, you have the right
to withhold the disclosure of any or all of the categories of directory information listed below.
Please consider very carefully the consequences of any decision by you to withhold any category of directory
information. Should you decide to inform the College not to release any or all of this directory information, any
future requests for such information from non-institutional persons or an organization will be refused.
The College will honor your request to withhold any of the categories listed below but cannot assume
responsibility to contact you for subsequent permission to release them. Regardless of the effect upon you, the
College assumes no liability for honoring your instructions that such information be withheld.
Please mark the appropriate boxes and affix your signature below to indicate your disapproval for the
institution to disclose the following public or directory information.
__________________________________________ ___________________________________________
Student (Last Name) (First Name) Semester/Quarter Year
__________________________________________ ___________________________________________
Student Identification Number Date
__________________________________________ _
Student Signature
If this form is not received in the Office of Student Records prior to the current semester Withdraw Date, it will
be assumed that the above information may be disclosed for the remainder of the current academic year.
__ Dates of Enrollment
__ Degrees and Certificates Received
__ Awards and Honors Received
__ Student’s Name
__ Classification
__ Full/Part-time Enrollment
__ Program of Study
Note: Modification of this Form requires approval of OGC
