STUDENT INFORMATION:
Student ID: @_______________________________________ Phone: __________________________________________
Name: Last _____________________________________ First _____________________________________ M.I. _______
Local Address: _______________________________________________________________________________________
Street City State Zip Code
REQUIRED SIGNATURE:
Please withhold the release of directory information about me until I rescind this request, in writing, to the Oce of
Records and Registration.
Student Signature: ___________________________________________________________ Date: ___________________
RELEASE OF DIRECTORY INFORMATION REGARDING STUDENTS:
Public Law 93-380, Privacy Act of 1974, permits the release, for the purpose of identication and record keeping, of the specic
items listed below unless a student has submitted a written request that this information not be released.
1. Name
2. Address (campus, local or home address)
3. Telephone number
4. Program and concentration(s) and minor(s)
5. Student activity participation; including athletics
6. Weight and height (athletic teams)
7. Dates of attendance
8. Full-time, three-quarter time, half-time or less than half-time enrollment status
9. Anticipated graduation date
10. Class level
11. Degrees and awards received
12. Date of graduation
13. All educational institutions previously attended
14. Academic awards, scholarships, and/or honors received
15. Student photograph
Request for Withholding the Release
of Directory Information
Each student has the right to prevent the release of directory information indicated above by notifying the Oce of Records
and Registration in writing. Such notication must be submitted to the Oce of Records and Registration no later than the
end of the “ADD Period” established by the University for each academic semester or session. Once a written request to
withhold information has been received, it will remain in eect until the student rescinds the request in writing to the Oce of
Records and Registration.
Note: Your name will not appear in any ocial University publication, including the commencement program. The Privacy Act
does establish some specic instances in which public information may be released even though you have requested a public
information hold.
Mail or Fax Completed Form to:
Oce of Records and Registration, Edinboro University, Hamilton Hall, 210 Glasgow Rd, Edinboro, PA 16444,
Fax: 814.732.2130, Phone: 814.732.3501
Created: 3/13/2003 • Revised 10/2/2019
