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Privacy Request to Withhold Directory Information

MISSOURI SOUTHERN STATE UNIVERSITY
OFFICE OF THE REGISTRAR




Under the provisions of the Family Educational Rights and Privacy Act of 1974 (FERPA), as Amended, you have the right to withhold the disclosure of the Directory Information.

Directory Information Includes:


Student's name, address, telephone listing, e-mail address, major field of study, dates of attendance, degrees, enrollment status (full-time or part-time), honors and awards received, participation in officially recognized activities and sports (includes height and weight of team members), most recent previous educational agency or institution attended, date and place of birth, photograph, grade level (freshman, sophomore, etc.), next of kin or spouse (emergency only).

Please consider very carefully the consequences of any decision by you to withhold “Directory Information”. Any future requests for such information from non-institutional persons or organizations will be refused.

The institution will honor your request to withhold the “Directory Information” but cannot assume responsibility to contact you for subsequent permission to release the information. Regardless of the effect upon you, the institution assumes no liability for honoring your instructions that such information be withheld.

CAUTION: Invoking this request will prevent your name from appearing in items such as news media announcing academic honors, the commencement program upon graduation, and restrict MSSU from verifying data to third parties such as enrollment and degree information, and other similar restrictions. Please consider these consequences carefully before submitting this form.

Please respect the confidentiality of my records. Do not release any information concerning me or my records, both past and future, without my written consent.
*Name: 
*Student ID Number: 
THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMATS UPON REQUEST. IF YOU NEED ASSISTANCE, PLEASE CONTACT THE REGISTRAR'S OFFICE at (417)625-9515.
The following information will constitute as an electronic signature.
*Student E-Signature: 
*Today's Date: 
SID
PIN