Admissions and Records Office
Palo Verde College
One College Drive
Blythe CA 92225
REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION
ALL STUDENTS:
The Family Educational Rights and Privacy Act designates certain information related to students as “Directory
Information” and gives the college the right to disclose such information to anyone inquiring without having to ask students
for permission, unless the students specifically request in writing that all such information not be made public without their
written consent. The categories of “Directory Information” are listed in the Palo Verde College policy statement on privacy
rights, a copy of which is available upon request from the Admissions and Records Office. If you wish to withhold the
disclosure of all of the items of “Directory Information,” fill out the form below and submit it to the Registrar.
This form must be received in the Admissions and Records Office within the first two weeks of each semester. If it is
not received in that office by that date, all directory information will be disclosed for the remainder of the semester. This
form will remain in effect until the student notifies the Admissions & Records Office (in writing) to remove their “Request to
Prevent Disclosure of Directory Information”.
Please consider very carefully the consequences of any decision made by you to withhold any category of “Directory
Information”, as any future requests for such information from non-institutional persons or organizations will be refused. In
addition, recognition for scholastic achievements, scholastic honors and/or awards will also be withheld. Palo Verde
College will honor your request to withhold all of the categories listed but cannot assume responsibility to contact you for
subsequent permission to release them. Regardless of the effect upon you, Palo Verde College assumes no liability for
honoring your instructions that such information may be withheld.
________________________________________________________________________________________________
I have carefully read the above and request that all “Directory Information” not be disclosed to non-
institutional persons or organizations by the College without my prior written permission:
Term (check one) Fall Spring Summer 20_______
Student’s Printed Name _____________________________________________________________
Social Security # ________________________________
Student’s Address _________________________________________________________________
City ______________________________ State ___________________ Zip _______________
Student’s Phone Number __________________________
Today’s Date ____________________ Student’s Signature ________________________________
Return completed form: Admissions and Records Office, Palo Verde College, One College Drive,
Blythe CA 92225
11/2004
