Request to Prevent Disclosure of
Directory Information under FERPA
Updated: July 6, 2015
For student use
The Family Educational Rights and Privacy Act (FERPA) established in 1974 was enacted to protect students’
personal and academic records. FERPA requires certain protective practices to be in place for personally
identifiable information of all enrolled students.
Instructions
Fill out the information below to block the release of Directory Information about your educational record at
Black Hawk College.
Student Information
First Name _______________________________ Last Name _______________________________________
Student ID _______________________________
Directory Information Blocked
The following student information is classified as Directory Information and will be blocked from release by
Black Hawk College, except as required by law:
•
Student’s name
•
Participation in officially recognized activities and sports
•
Address
•
Telephone listing
•
Weight and height of members of athletic teams
•
e-mail address
•
Photograph
•
Degrees, honors, and awards received
•
Major field of study
•
Terms of attendance
•
The most recent educational agency or institution attended
•
Enrollment status (e.g., certificate or associate’s, full-time or part-time)
Moline, IL 61265
Email: registrar@bhc.edu
Please acknowledge below and return to Enrollment Services if you consent for the College to block
Directory Information from your educational records.
I consent that Black Hawk College may not disclose directory information from my educational record.
Student Signature _________________________________________________ Date __________________
*Signature line may be left blank, and e-signature will be accepted when completed form is sent from a student’s
myBlackhawk email account.
Please Note: This release form will remain valid unless specifically revoked in writing by the student.
Created by Enrollment Services, July 2015.
