Fillable Authorization-for-non-disclosure-of-directory-information Non-Disclosure Form

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Authorization-for-non-disclosure-of-directory-information Non-Disclosure Form

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The Authorization-for-non-disclosure-of-directory-information Non-Disclosure Form form is 2 pages long and contains:

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File type: PDF

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Office Use Only
Received by:
Campus:
INDIAN RIVER STATE COLLEGE
Student Records Department
(772) 462-7460
Authorization for Non-Disclosure of Directory Information
in accordance with Family Educational Rights and Privacy Act
(FERPA – 34 CFR Part 99)
Student ID#:
Student’s Printed Name:
Last:
Date of Birth (Month/Day
First:
/Year):
Middle:
Indian River State College maintains student records in accordance with federal law, Florida Statutes,
and State Board of Education Rules.
Pursuant to Florida Statute, 1002.21 and 1002.22 and the Family Educational Rights and Privacy Act
of 1974 (FERPA), the College may publish and release general public Directory Information relating to
students.
IRSC student Directory Information includes a student’s name, address, major field of study,
participation in officially recognized activities and sports, weight and height of members of athletic
teams, dates of College attendance, degrees, awards, and scholarships received, and the most recent
previous educational agency or institution attended by the student.
Under the provisions of FERPA you have the right to withhold disclosure of such Directory Information.
Your completion of this Authorization for Non-Disclosure will result in the withholding of Directory
Information noted below from any third party. This Authorization will also require that you submit photo
identification to complete transactions at IRSC.
Non-Disclosure Restrictions
Restrict ALL Directory Information (ALL items listed below)
OR, Select Individual Restrictions:
No Release of Name No Release of Sports/Activities Participation
No Release of Degrees/Awards Received No Release of Address
No Release of Weight and Height No Release of Scholarships Received
No Release of Field of Study No Release of Dates of Attendance
No Release of Institutions Attended
Once you have made your non-disclosure selections, your restrictions will remain on file and be
enforced until you complete the Cancel Request.
Cancel Request
I request that the above Authorization for Non-Disclosure of Directory Information be cancelled.
Student’s Signature Date Cancelled
FOR OFFICE USE ONLY
Records Specialist Date Entered
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Authorization-for-non-disclosure-of-directory-information Non-Disclosure Form

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Completed 3 November 2019

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