Fillable Directory Information Restriction Request Under the provisions of (Lewis-Clark State College)

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Directory Information Restriction Request Under the provisions of (Lewis-Clark State College)

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Revised: 2/10/2016
Directory Information Restriction Request
Under the provisions of the Family Educational Rights and Privacy Act of 1974 as Amended, you have the
right to withhold the disclosure of any or all of the directory information listed below.
Please consider very carefully the consequences of any decision by you to withhold any item of directory
information. Should you decide to restrict Lewis-Clark State College from releasing any or all of your
directory information, any future requests for such information from non-LCSC persons or organizations will
be refused. Directory information includes the following:
• Name
• College Level (Fr., So., Jr., Sr.)
• Major/Minor
• Withdrawal Dates
• Dates/Terms Attended
• Full/Part Time Status of Attendance
• Degrees/Certificates Awarded
• Previous Colleges Attended
• Academic Honors
• Athletic Information
Please mark the appropriate boxes and sign below to indicate your disapproval for the institution to
disclose the following directory information.
Academic Information such as:
Attendance Information such as:
• Major/Minor
Withdrawal Dates
• Dates/Terms Attended
Full/Part Time Status of Attendance
• Degrees/Certificates Awarded
Previous Colleges Attended
• College Level (Fr., So., Jr., Sr.)
Athletic Information
• Academic Honors
(includes Dean and President’s Lists)
Secure ALL Information
LCSC will honor your request to withhold any of the items listed above but cannot assume responsibility to
contact you for subsequent permission to release them. Regardless of the effect upon you, LCSC assumes no
liability for honoring your instructions that such information be withheld.
Student Name (printed) __________________________________ Date ___________________________
Student Signature _______________________________________ ID # ___________________________
Semester/Year _________________________________________
This form will be honored by the College until rescinded in writing by the student. This
means if the student experiences life changes such as divorce, parental issues, etc. it STILL
REMAINS the student’s obligation to inform the Office of Admission/Registrar IN
WRITING to rescind this form to prevent student data from being released to the
individuals listed above.
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Directory Information Restriction Request Under the provisions of (Lewis-Clark State College)

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Completed 22 August 2020

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