Request to Withhold Directory Information

Please fill out this form, sign and:

Return to:

Highlands Middle School

1850 Plainfield Road

LaGrange, IL 60525

Highlands Elementary School

5850 Laurel Avenue

LaGrange, IL 60525

I hereby request District 106 to withhold student directory information which includes:

  1. Name
  2. Address (local, permanent, and electronic mail)
  3. Telephone numbers
  4. Grade
  5. Home Room
  6. Student activities
  7. Weight/height (athletic teams)
  8. Date(s) of attendance
  9. Enrollment status (enrolled or not enrolled)
  10. Date of graduation
  11. Awards received and where received

Filing this form will preclude District 106 from releasing directory information to anyone without express written consent. To process this request you must present this form along with photo identification to any school office or mail this form along with a copy of photo identification to the address listed above.

I have read this form carefully and understand the consequences of my decision to prevent release directory information. I understand:

Today's Date: _____________________________________

Student Name: _____________________________________

Parent/Guardian Name: _____________________________________

Parent/Guardian Email: _____________________________________

Please review your entries on this form. If all of the information is entered correctly please sign and submit the form to the address at the top of the form.

Signature: _____________________________________ Date: ___________________

Office Use Only

Received By: ____________________________________Date Received: ___________________

Revised 2/20/2018