Student Privacy Hold Form

I, ______________________________________, request that Youngstown State University NOT DISCLOSE my student directory Information without my prior written permission. However, I understand this information may be provided to Youngstown State University officials and other specified individuals as prescribed by FERPA.

I understand the consequences of this decision to withhold my student directory information, as any future requests for such information will be refused. Examples of potential impacts are: no acknowledgement of my attendance at YSU to potential employers, no verification of degrees to requestors, no printing of my name in the commencement program and no press releases pertaining to graduation and/or honors.

YSU will honor my request to hold student directory information, but cannot assume responsibility to contact me for subsequent permission to release it. The privacy hold will remain in effect until the Registrar's Office receives a written request from me to release the hold. If, in the future, I wish to rescind my request, I must return to the office where you submitted this form.

NOTE TO STUDENT: To finalize the processing of your authorization, you must deliver this form IN PERSON to the Office of the Registrar, Penguin Service Center along with photo identification. This form will not be accepted without proof of identification in order to ensure the protection of your information

Student Signature: _________________________________________________

Student ID#: ____________________________________     

Date: ________________________________________

If, in the future, you wish to rescind your request to release records, you must return to the office where you submitted this form and sign below:

I hereby rescind my request for student privacy hold pertaining to my records. I no longer want Youngstown State University to withhold directory information from those who may request it.

Student Signature: ________________________________________________ 

Date: ______________________________


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Rev. 6/13/16

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