2/2016
REQUEST FOR NON-DISCLOSURE OF DIRECTORY INFORMATION
NOTIFICATION TO ALL STUDENTS:
The items listed below are designated as Directory Information and may be released for any purpose at the
discretion of our institution.
Under the provisions of the Family Educational Rights and Privacy Act of 1974, you have the right to withhold the
disclosure of any or all of the categories of Directory Information which are 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 released any or all Directory Information, any future requests for such
information from non-institutional persons or organizations will be refused.
Daemen 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. This request for non-discloure will
remain in effect until the student provides written instruction to change this status.
Please mark below the appropriate boxes and affix your signature, complete the personal identifying information
indicated, and the date of signature, to activate the non-disclosure specified below.
CATEGORY 1: WITHHOLD
DISCLOSURE
Name, address, email address, telephone number, dates of attendance, □
date and place of birth, enrollment status (advance registration and registration
data; anticipated graduation year; class status), resident status (commuter; resident),
institutions attended prior to admission/readmission, major field(s) of study, declared
minors, awards, honors (includes Dean’s List and Commencement honors/awards,
Honors program), degree(s)/certificates conferred (including dates of conferral)
CATEGORY 2:
Participation in officially recognized sports and/or activities, physical factors (height, □
weight of members of athletic teams)
I hereby request that Daemen College not release the category(ies) of directory information which I have indicated
above. I have read all of the information referenced above and understand the consequences of my action.
_____________________________________ ________________ _____________
Student’s Signature Student ID# Date
Main St., Amherst, NY -
Office of the Registrar
DS 120
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signature
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