FERPA withold release form June 2014

LINCOLN LAND COMMUNITY COLLEGE Privacy and Your Educational Records OFFICE of ADMISSIONS, RECORDS & REGISTRATION 217-78...

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LINCOLN LAND COMMUNITY COLLEGE

Privacy and Your Educational Records OFFICE of ADMISSIONS, RECORDS & REGISTRATION 217-786-2424

PERMISSION TO

RELEASE INFORMATION TO DESIGNATED INDIVIDUAL(S)

Under the provisions of the Family Educational Rights and Privacy Act (FERPA) of 1974, you have the right to allow release of personably identifiable information, including academic and financial records, to a designated individual or individuals. Lincoln Land Community College will honor your request to release the information as listed but cannot assume responsibility to contact you to deny future release of this information if valid release end date is not provided. Regardless of the effect upon you, the college assumes no liability for honoring your instructions that such information be released. Please review the items listed, sign and date to indicate your request that Lincoln Land Community College release information to a designated individual(s). You do have the option to limit release to specific information / records items as listed below. Mark as appropriate to your needs:

Release per verifiable ___ written ___ in-person ___ phone ___ email request only. Release to the individual(s) as noted only those LLCC records as marked: ___ Transcripts / grades only ___ Enrollment / attendance only ___ Current schedule only

___ Financial records only

___ other:______________________________________________

___ All academic, financial, enrollment, attendance and schedule information /records Name #1: _______________________________________________

Relationship (optional): ____________ Phone: ___________________

Address/City/State/Zip: ______________________________________________________________________________________________________ Name #2: _______________________________________________

Relationship (optional): ____________ Phone: ___________________

Address/City/State/Zip: ______________________________________________________________________________________________________

I request that this release remain valid until:

Month__________

Year: ___________

By my signature I agree to the release of information to the individuals as noted. By my signature I understand this request will remain in effect as noted or until I request otherwise. SIGNATURE: ______________________________________________________________________________

DATE: _____________

PRINT NAME: _____________________________________________________________________________ LLCC I.D#. or S.S.N. : ________________________________________________________________________

WITNESSED BY STAFF: ____________________________________________________________________

DATE:________________

Please note that your signature must be witnessed by a LLCC employee.

Staff: Return to Student Records Records Office only: STRK notes, RGPE “Directory” blank “Privacy” L Processed by:________________ Date: _____________

LINCOLN LAND COMMUNITY COLLEGE

Privacy and Your Educational Records OFFICE of ADMISSIONS, RECORDS & REGISTRATION 217-786-2424

RESTRICT RECORDS ACCESS OR DENY DISCLOSURE OF DIRECTORY INFORMATION Deny Disclosure of Directory Information The following items are designated as “Directory Information” and may be released for any purpose at the discretion of Lincoln Land Community College. Name, address, telephone number, dates of attendance, year in school, previous institution(s) attended, major field of study, awards, honors, degrees earned, past and present participation in officially recognized sports and activities, physical factors (height, weight of athletes), date of birth. Under provisions of the 1996 Solomon Amendment Lincoln Land Community College is required to release, upon request, directory information to recruiters of the United States Military. Under the provisions of the Family and Educational Rights and Privacy Act (FERPA) of 1974, you have the right to withhold the disclosure of the “Directory Information” to any entity outside LLCC. By my signature I request that my Directory Information not be released for any purpose by Lincoln Land Community College. I understand this restriction will remain in effect as noted or until I request otherwise. SIGNATURE: __________________________________________________________________ PRINT NAME: _________________________________________________________________ LLCC ID# or SSN: ______________________________

DATE: ________________

Request to remain valid until: ________________

WITNESSED BY STAFF:________________________________________________________ DATE:________________________________________ Staff: Return to Student Records Records Office only: STRK notes, In RGPE “Directory” N “Privacy” blank. Processed by:_____________________ Date: _________

Restrict Process & Records Access to In-Person Only You have the right to request that all of your enrollment, records and financial activities and transactions be restricted to in-person processing only. This restriction insures that all enrollment, records and financial transaction will be conducted only by you and only in-person with proper identification. This restriction does not apply to your secure WebAdvisor access. Lincoln Land Community College will honor your request for restricted access but cannot assume responsibility to contact you for future permission to reverse this request. Regardless of the effect upon you, the college assumes no liability for honoring your instructions that access be restricted. By my signature I request a “Do not release information” restriction to my LLCC records. I understand this restriction will remain in effect until I request otherwise. I understand that any records or enrollment changes not completed securely online in WebAdvisor will now be made by me only in-person providing a photo ID. SIGNATURE: ____________________________________________________________ PRINT NAME: ___________________________________________________________ LLCC ID# or SSN: __________________________________ DATE: ____________

Request to remain valid until: ________________

WITNESSED BY STAFF:___________________________________________________

DATE:________________________________________

Staff: Return to Student Records Records Office only: STRK notes, RGPE “Directory” N “Privacy” D 6/14

Processed by:_______________________ Date: __________