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# Authorization to Release Directory Information

KSU STUDENTS:

The Family Educational Rights and Privacy Act (FERPA) designates certain information as “directory information.” This applies to information such as name, address, phone number, date and place of birth, major field of study, participation in officially recognized activities and sports, weight/height (athletic teams), degrees and awards received, dates of attendance, and the most recent previous educational agency or institution attended. Under the provisions of the Family Educational Rights and Privacy Act, you have the right to withhold or release disclosure of such directory information.

Filling out this form will allow the University to release directory information to the public without your written consent.

By releasing the privacy restriction on your record, you allow the University to acknowledge your enrollment to anyone who requests verification of enrollment. This would include deferring loan repayments or inquiries from a prospective employer.

I have carefully read the above and request that “directory information” be disclosed to non-institutional persons or agencies by Kentucky State University without my written permission. I understand that authorization is applicable until such time as I request that it be withheld in writing.


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td style='text-align: center; word-wrap: break-word;'>Student Printed Name (First MI Last)</td><td style='text-align: center; word-wrap: break-word;'>Date</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Student Signature</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Student Birthdate</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Student ID number</td><td style='text-align: center; word-wrap: break-word;'>Student SSN</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Form Revised 2/ 2009</td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>