PERMISSION TO RELEASE NON-DIRECTORY INFORMATION

Mid-Plains Community College designates directory information as defined by the Family Educational Rights and Privacy Act.  These items include the student's name, major field of study, dates of attendance, permanent phone number, local phone number, permanent address, local address, previous schools attended, nature of any degrees granted and dates conferred, student classification, photograph, height and weight of athletic team members, participation in officially recognized activities, honors and awards earned, and student e-mail addresses.  Appropriate information may also be disclosed in cases of health or safety emergency.

Directory information may be included in appropriate college directories and publications or otherwise disclosed by designated staff members unless a student files a written request with the office of Registration & Records during the first 10 days of a given semester.

For more information, visit the MPCC website at:  Consumer Information (mpcc.edu).

Today's Date:

MPCC Student ID:

First Name:

Middle Name:

Last Name:

To allow release of specific information to designated individuals otherwise restricted by the Family Educational Rights & Privacy Act (FERPA) or the Higher Education Act (HEA), click Next.

DESIGNATED INDIVIDUALS

Upon their request, allow release of information specified on the following tab to the designated individual(s) below:

If you wish the individual(s) designated below to access your information online via their own network account/login, rather than complete this form, you must be logged into CampusWeb and "Define New/Update Permissions" on the Parent/Guest tab.

PARENT/GUARDIAN/SPOUSE (or other individual):

First/Last Name (1)

Cell Phone Number

E-mail

First/Last Name (2)

Cell Phone Number

E-mail

HIGH SCHOOL (if enrolling in MPCC courses while in high school):

School Name

Contact Person's First/Last Name

Contact Person's E-mail

Phone Number

Fax Number

OTHER BUSINESS/ORGANIZATION (if any):

Business/Organization Name

E-mail

Phone Number

Fax Number

START/END DATES:

This release begins:

This release will end (select date):

AUTHORIZATION

SELECT ALL THAT APPLY:

ACADEMIC:  By checking this box, MPCC may discuss grades, GPA, academic standing, student schedule, class participation/performance, attendance, and program requirements.

FINANCIAL:  By checking this box, MPCC may discuss payments, bills, refunds, holds, FAFSA, financial aid, scholarships, and 1098-T.

STUDENT LIFE:  By checking this box, MPCC may discuss student conduct, residence hall behavior/activity, athletics, and clubs.

If there is any additional information not covered above that you would like to release, please provide it here:

By selecting SUBMIT, you are authorizing MPCC to release selected information above to your designated persons(s) and/or organization(s).  Please review all information you have provided, and once you are satisfied with your selections, click the SUBMIT button.  If for any reason you decide you do not want to release non-directory information, simply close out of this form.