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LOUISIANA DELTA COMMUNITY COLLEGE
Division of Student Affairs Department of Enrollment Services
Revocation of Authorization for Release of Information
OF AUTHORIZATION FOR THE RELEASE OF GRADE(S), ACADEMIC
ENROLLMENT STATUS, ATTENDANCE AND FINANCIAL
I no longer authorize Louisiana Delta Community College (LDCC) to release my academic and
enrollment status, class schedule, attendance, financial and other related information to my
parent(s), or named individuals or entities listed below.
If I have previously authorized the release of information to any parties not named in this form, I understand that I
must submit and sign an additional revocation form(s) in order for those prior authorizations to be revoked.
Enrollment Services use only
Form of ID Identity Verified By:
Date:
Student Name: (Print)
St
St
udent ID Number:
Date:
__________________ ________________________________
______________________
Please
Name
Relationship
Address
City, State, Zip City, State,
Em
ail Email
