After carefully reviewing and understanding the Information Restriction Form, below, insert your FULL Name and CWID. 

Click on each check box that applies to your preferences.  Print the form and either mail to Longwood University,

Registration Office,201 High Street, Farmville, VA  23909, or deliver in person to the Registration Office.

 

Student Information Restriction Form

Longwood University

 

NAME

                        Last                                       First                                             Middle

 

CWID  

If you wish to restrict the release of information, this form must be received by the Registration Office on or before the last day to add a class for each semester.  The University reserves the right to indicate to potential inquirers whether or not a student is currently enrolled and/or of the dates of attendance.  Under the Family Educational Rights and Privacy Act (FERPA), Longwood University is no longer required to give a student prior notice when responding to a Federal grand jury subpoena or other law enforcement subpoena which specifies that the student not be informed of the existence of the subpoena.  Longwood University student records policies comply fully with FERPA.

Indicate with an "ü" all categories you wish to restrict the release of information:       

Name                                   Major                                  Classification 

Degrees Awarded                Honors/Awards                  E-Mail Address

Phone Number                    Parent's Name                     Parent's Address

Permanent Address                                                                Local Address  

Address for Mailing Lists                                     Previous Institution Attended

I hereby authorize Longwood University to restrict the release of information indicated by myself above with an "ü" until such time and on such occasions that I amend this agreement or provide a signed written statement which expressly authorizes the release of this information.  I am aware that this restriction of this information is to all parties, including and not limited to academic honors, clubs, organizations, sports teams, and general information. 

Student Signature__________________________________________________

Date____________________________________________________________

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OFFICE USE ONLY

Date Processed____________________________Staff______________________________________________

REG-12(4/04)