Registrar’s Office
303-273-3200
REQUEST TO PREVENT DISCLOSURE OF
DIRECTORY INFORMATION

The items listed below are designated as “Directory Information” and may be released for any purpose at the discretion of
Colorado School of Mines. Under the provisions of the Family Education Rights and Privacy Act of 1974, also known as
the Buckley Amendment, you have the right to withhold the disclosure of all of your Directory Information.

By signing this form, you are obligating Colorado School of Mines NOT to release any Directory Information. Any
request from a third party, including loan and insurance companies, will be refused. Your information will remain
private, releasable only with your express consent by signature. The Registrar’s Office will not acknowledge that you are
even a student.

Please consider carefully the possible effects of withholding disclosure of information. By signing below, you indicate
your desire that Colorado School of Mines not release any information concerning your record, including Directory
Information.

This form must be turned in at the Registrar’s Office by the end of the second week of classes for the Fall semester in
which the student is enrolled in order that the student’s information not be printed in the Student Directory. Until this
form is received in the Registrar’s Office, Directory Information may be released.

Directory Information:
Name
Full/Part-time
Status

Current address and phone number

Degrees awarded
Permanent address and phone number
Last school attended
Date
of
birth
Participation
in
officially recognized activities and sports
Major field of study



Class (FR, SO, JR, SR, Graduate Student)
Dates
of
attendance
Academic
Honors

By signing this you also understand that some information may be available to other class members and the professor in
courses that use the Blackboard system. In order to participate in these classes, it is necessary that your name be visible
to other members of the class and the faculty member only.

Printed Name: __________________________________________________________________

Student Signature:
____________________________________________________________

Campus Wide ID Number (CWID):
_______________________________________________

Date: _________________________________________________________________________

REVOCATION
By signing below, I revoke my request to make my records private under FERPA. My records will revert to normal
status, allowing normal disclosure of directory information and disclosure to parties allowed under FERPA.

Printed Name: __________________________________________________________________

Student Signature:
____________________________________________________________

Campus Wide ID Number (CWID):
_______________________________________________

Date: _________________________________________________________________________
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