FERPA Restriction Form
NAME:______________________________________________________________________________________
ID#: _________________________________
PLEASE RESTRICT ALL INFORMATION ON MY RECORDS AT ICC. I DO NOT WANT ANY
INFORMATION RELEASED WITHOUT MY APPROVAL.
I understand by completing this form I will be required to complete all academic
actions through my MyICC (eServices) account or in person with a photo ID. This
includes asking questions pertaining to my academic and financial records, adding
and dropping classes, requesting password resets, etc.
SIGNATURE: _______________________________________________________________________________
DATE: ______________________________
By typing your name above, you are signing this form electronically. You agree your
electronic signature is the legal equivalent of your manual signature on this form.
5
/2020
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