Delta ID: __________________
Name:____________________________________________________________________________________
First Middle Maiden Last
Major: ____________________________ Signature: ______________________________________
______________________________
____________________________________
___________________________________________
___________________________________
_________________________________________
·
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
LOUISIANA DELTA COMMUNITY COLLEGE
Division of Student Affairs Department of Enrollment Services
Request to Withhold Directory Information
STUDENT
INFORMATION:
Under the rights granted to me by the Family Educational Rights and Privacy Act, I request that items defined
as directory information by Louisiana Delta Community College (LDCC) not be released without my written
consent. I understand that my request to withhold such information will remain valid indefinitely or until I
submit a written request to the LDCC Registrar’s Office to lift the restriction. Further, I understand that this
form is not valid unless it is completed and submitted to the Registrar’s Office along with a photo ID. I
understand that the following informational items are defined as directory information by LDCC and will not
be released:
Name
Address (es)
Telephone number
E-mail address
Date of birth
Dates of attendance
Degrees and dates received
Current class schedule*
Classification (e.g., freshman, senior)
College and major
Full-time/part-time status
Level (e.g., undergraduate, graduate)
Academic honors
Awards and scholarships
Most recent institution attended, including high school
Photograph*
Participation in sports or other recognized activities
Weight and height of members of athletics teams
*released only to LDCC, local, state, and federal law enforcement agencies
FOR OFFICE USE ONLY:
For Office Use Only:
Processed By:
Date:
Effective Term:
Advisor:
Bastrop Jonesboro Farmerville Lake Providence Monroe Ruston Tallulah West Monroe Winnsboro
Member of Louisiana Community and Technical College System
• • • • • • •
