Vital Statistics Change Form
Date
Name (please print) Student ID Number
Please Change My:
[ ] Social Security Number [ ] Name
[ ] Date of Birth
[ ] Don't Know
[ ] Change of FERPA Disclosure Status
Old Information (Only if name and/or Social Security number has changed):
Student ID Number Social Security #_____
Name (last/first/middle/former name)
New Information:
Complete all that apply.
Student ID Number Social Security #_____ Date of Birth
Name (last/first/middle/maiden)
Address
Street Apt# City State Zip
Phone number
Cell phone number
FERPA Change of Status Statement
I release Polk State College from my FERPA non-disclosure election effective immediately. I understand that I cannot hold the
college liable for any consequences resulting from the release of directory information. Initial ______
Certification
I am requesting Polk State College to make the above changes to my student records. I understand that providing false infor-
mation to Polk State College may result in disciplinary action and possible legal action.
Printed Name Signature Date
For Polk State College Use Only
Original term of entrance/re-admittance Employee signature Date
Documentation provided:
Polk State College is committed to and encourages equal opportunity/equity/access for its programs, services, and activities.
[ ] Other (specify)_________________________________
Updated: 11/5/19
Note: You must provide your social security card and a valid picture ID for a SS# number change/addition. A court
document or valid picture ID such as a Driver’s License showing verification of correct name is required for name
changes or date of birth.
