OFFICE USE ONLY
Received by: Initials __________________ Date __________________
Entered: BIO Initials __________________ Date __________________ 6/2018
DIRECTORY INFORMATION NON-DISCLOSURE FORM
Per compliance with The Family Educational Rights and Privacy Act of 1974 (FERPA)
Records Office PO Box 38 Wentworth NC 27375 336.342.4261 Fax: 336.342.1809 records@rockinghamcc.edu
This form must be filed with the Record’s Office if you do not wish any or all directory information disclosed without
your prior consent. Directory information otherwise may be made available to any parties deemed to have a
legitimate educational interest in the information. The requests indicated on this form may be changed at any time
by filing a new form with the Record’s Office.
I. __________________________________________________ ________________________________
STUDENT NAME (Print) RCC STUDENT ID NUMBER (7 Digits)
___________________________________________
DATE OF BIRTH (mo/day/yr)
II. SELECT AND INITIAL BY ONE (A, B, OR C)
a. _______ Do not disclose any directory information without my prior consent. (If you initial
here, skip III. STUDENT SIGNATURE)
b. _______ Do not disclose the following directory information without my prior consent. (Initial
the items which you do not want released and go to STUDENT SIGNATURE.)
_______ Name
_______ Date and place of birth
_______ Program of study
_______ Enrollment status
_______ Dates of attendance
_______ Degrees and awards received
_______ Most recent previous school attended
_______ Participation in officially recognized activities
_______ Weight and height of athletes
c. ________ Withdraw my prior instructions to not release directory information. I now authorize
RCC to release all of my directory information to parties with a legitimate
educational interest.
III. __________________________________________________ ________________________________
STUDENT SIGNATURE DATE
