Mike DeWine, Governor

Paolo DeMaria, Superintendent of Public Instruction

Lou Maynus, Superintendent, Ohio School for the Deaf and Ohio State School for the Blind

In accordance with the Federal Educational Rights and Privacy Act of 1974 (FERPA) and ORC 3319.321, as amended, your student’s education records are maintained as confidential and, except for a limited number of special circumstances listed in FERPA, will not be released to a third party without the parent/student’s prior written consent. FERPA does, however, allow OSD/OSSB to release student “directory information” without obtaining the prior consent of the parent/student. If you do not want the release certain types of directory information without your prior consent, you may choose to “opt-out” of this FERPA exception by signing this Form. Directory information of a student who has opted-out from the release of directory information, in accordance with this procedure for opting-out, will remain flagged until the parent/student requests that the flag be removed by revoking this Form in writing to OSD/OSSB.

I request the withholding of the following personally identifiable information identified as Directory Information under FERPA and ORC 3319.321. I understand that upon submission of this Form, the information checked below cannot be released to third parties without my written consent or unless OSD/OSSB is required by law or permitted under FERPA to release such information without my prior consent, and that the checked directory information will not otherwise be released from the time OSD/OSSB receives my Form until such time as this Opt-Out Form is rescinded in writing to OSD/OSSB. I understand that I may not opt-out of the use of my student ID number because it is necessary identifying information for OSD/OSSB. I further understand that if directory information is released prior to OSD/OSSB receiving my Opt-Out Form, OSD/OSSB may not be able to stop the disclosure of my directory information. I understand that I may request information about how my directory information is used by contacting OSD/OSSB.

OR

500 Morse Road Columbus, Ohio 43214 www.osd.oh.gov

Phone: (614) 995-1566 Fax: (614) 995-1567

5220 High Street Columbus, Ohio 43214 www.ossb.oh.gov

Phone: (614) 752-1152 Toll Free: (800) 310-3317 Fax: (614) 752-1713

If student is under the age of 18, a parent or guardian must sign this form to effectuate the Opt-Out.