Adopted: February 1987
Revised: January 2023
Download 505.2.4P - Request for Lists of Directory Information
This form is to be completed by persons requesting lists of student directory and yearbook information. This request and the required fee should be submitted to Student Information. As provided by law, military recruiting officers shall not be charged a fee. Any alteration of the lists is not permitted.
1. Identifying Information to Facilitate Access to Data (please print)
____ Name__________________________________________________________________
____ Agency/business represented _________________________________________
____ Address/city/zip_______________________________________________________
____ Telephone number_____________________________________________________
____
____ Email address_________________________________________________________
2. Request for Lists (indicate the quantity of each list you are requesting):
(Note: All lists are provided in alphabetical order. In accordance with state and federal law, addresses and home telephone numbers of high school students are only available as requested by military recruiting officers and institutions of higher education, see section C.)
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A. Names of ALL students (kindergarten-grade 12, sorted by grade)
Total
o Electronic list @ $30 each $30 x _____ lists = $_______
o Paper list @ $40 each $40 x _____ lists = $_______
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B. Names and school email addresses of students in grades 9-12 (check boxes to indicate requested lists)
Apple Valley High School: o Seniors o Juniors o Sophomores o Freshmen
Eagan High School: o Seniors o Juniors o Sophomores o Freshmen
Eastview High School: o Seniors o Juniors o Sophomores o Freshmen
Rosemount High School: o Seniors o Juniors o Sophomores o Freshmen
School of Environmental Studies: o Seniors o Juniors
Area Learning Center: o Seniors o Juniors o Sophomores o Freshmen
Total
o Electronic list @ $10 each $10 X _____ lists = $_______
o Paper list @ $15 each $15 X _____ lists = $_______
Procedure 505.2.4P
Page 2
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C. Names, school email addresses, addresses and home telephone numbers of students in grades 9 11-12 (check boxes to indicate requested lists) (Note: These lists are only available to military recruiting officers and institutions of higher education, and may not be shared with any other person or organization, may not be copied and may not be given to someone else to copy.)
Apple Valley High School: o Seniors o Juniors o Sophomores o Freshmen
Eagan High School: o Seniors o Juniors o Sophomores o Freshmen
Eastview High School: o Seniors o Juniors o Sophomores o Freshmen
Rosemount High School: o Seniors o Juniors o Sophomores o Freshmen
School of Environmental Studies: o Seniors o Juniors
Area Learning Center: o Seniors o Juniors o Sophomores o Freshmen
Total
o Electronic list @ $30 each $30 X _____ lists = $_______
o Paper list @ $40 each $40 X _____ lists = $_______
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D. GRAND TOTAL OF ALL LISTS $_______
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3. Submit payment (payable to Independent School District 196) with this request to:
Student Information
Independent School District 196
3455 153rd Street West
Rosemount, MN 55068-4946
FAX – 651-423-7787
Signature______________________________________________________ Date______________________________
OFFICE USE ONLY
Request: Approved___ Denied___
____________________________________________________________________ ________
Student Information Date