Student NCL Form

STUDENT NCL FORM

Student Information

Date of Birth:    Student ID:

Email:    Phone:

Parent / Guardian (if student is a minor)

Student is a minor:

Relationship:    Phone:

Non-Consent / Restriction Selections

I request that the institution refrain from releasing the following categories of information about the student to third parties without my prior written consent (select all that apply):

Restrict all directory information (name, address, telephone, email, photograph)

Enrollment status / dates of attendance / class schedule

Academic records (grades, transcripts, GPA)

Photographs, video, and other media depicting the student

Financial information (billing, tuition status)

Other (describe below)

Duration and Exceptions

Restriction applies: Until revoked in writing    For current academic year    Specific date range: to

The following releases are expressly permitted even if the above restrictions are selected (select all that apply):

Release to appropriate officials when necessary to protect health or safety during an emergency

Release required by court order, subpoena, or other legal process

Release to school officials with legitimate educational interest

Certification and Acknowledgment

By signing below, I certify that the information provided on this Student NCL Form is true and accurate to the best of my knowledge. I understand that:

• this form restricts the institution's release of specified categories of student information to third parties without prior written consent, subject to the exceptions noted above;
• the restriction will not prevent the institution from disclosing information internally to authorized personnel with legitimate educational interest or as required by law, regulation, or valid legal process;
• a restriction will not be applied retroactively to information already disclosed prior to receipt and processing of this form;
• revocation of this restriction must be submitted in writing and will take effect upon institution's receipt and processing; revocation is not retroactive.

I acknowledge that misrepresentation on this form may be subject to institutional disciplinary action and that the institution may require additional documentation to verify authority to restrict release (for example, proof of guardianship).

Administrative Use Only

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