Vital Statistics Change Form
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1Vital Statistics Change Form
Date
Name (please print)
Student ID Number
Please Change My:
[ ] Name
[ ] Social Security Number
[ ] Change of FERPA Disclosure Status
[ ] U.S. Citizenship
[ ] Date of Birth
] International Student to Resident Immigrant Alien
[
[ ] Resident Immigrant Alien Number
[
[ ] Other (specify)_________________________________
Old Information (Only if name and/or Social Security number has changed):
Student ID Number
Social Security #_____
Name (last/first/middle/former name)
New Information:
Complete all that apply.
Student ID Number
Social Security #_____
Date of Birth
Name (last/first/middle/maiden)
Address
Street
Apt#
City
State
Zip
Phone number
Cell phone number
Other_______________________________________________________________________________________________________
FERPA Change of Status Statement
I release Polk State College from my FERPA non-disclosure election effective immediately. I understand that I cannot hold the col-
lege liable for any consequences resulting from the release of directory information. Initial______
Certification
I am requesting Polk State College to make the above changes to my student records. I understand that providing false informa-
tion to Polk State College may result in disciplinary action and possible legal action.
Printed Name
Signature
Date
For Polk State College Use Only
Original term of entrance/re-admittance
Employee signature
Date
Documentation provided:
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