Kirkwood School District
Request for Directory Information

Directory Information may be released without obtaining parental consent, unless a parent has chosen to “opt out” of the directory information clause.  The following information has been designated as “Directory Information”: student’s name, parent’s name, address, telephone number, electronic mail address, date of birth, grade level, enrollment status, participation in officially recognized activities and sports, photographs, weight and height of members of the athletic teams, dates of attendance, degrees, honors, awards received, and most recent previous school attended.

Date:
5/22/2012

I, , request the following "Directory Information"
from school or Kirkwood School District:
Please list type of information needed (Student's name, parent's name, address, phone, etc.)

Please state the reason the information is needed:

Date needed by: (Please allow 3-5 days for request to be processed)
(mm/dd/yyyy)

By signing/sending this letter, I understand that the information should only be used in conjunction for not-for-profit purposes, commercial vendors that support specific school interests (yearbooks, class rings) or non-politically affiliated activities.This information will not be sold or redistributed.I also agree to not discriminate on the basis of Kirkwood R-7 policies (sex, race, religion, age, national origin, handicap, or disability) or Kirkwood City Ordinance (sexual orientation and disability) in admissions or access to the activity or publication.

Name of organization:

Name of Contact Person:
Phone:
Address:
Email:
What is your perferred method of delivery (please check one):
Will pick up when called - phone number
US Mail
Electronic - email
You can submit this form here, print and mail to the address below or
fax to: 314-984-0002
Ginger Fletcher, Director of Community Affairs
11289 Manchester Rd, Kirkwood, Mo 63122
Note: Federal law requires local educational agencies (LEAs) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon request, with three directory information categories – names, addresses and telephone listings – unless parents have advised the LEA that they do not want their student’s information disclosed without their prior written consent.

By pressing the Submit button you are agreeing to a binding signature and submitting the form. Please PRINT the form for your records BEFORE submitting.


 

(The form is emailed to Community Affairs. Your approval will be determined and emailed back to you.)