Student ID#: ___________________ Date of Birth: ___________________
Last Name: ________________________________ First Name: _______________________ Middle Initial: __________
Consent to Release
I understand I am authorizing release of information contained in my education records to a third party. This consent does not
cover medical records held solely by Student Immunization Records or education records held by individuals or offices other than
the Office of the Registrar and/or the Financial Aid Office and the Business Office. It also does not authorize the disclosure of any
User Name or Password associated with my accounts.
This consent is valid for two years. I may revoke my consent at any time by submitting a signed written statement, or by signing
the Revocation of Consent to Release portion of this form.
In accordance with the Family Educational Rights and Privacy Act (FERPA), I consent to authorizing third party access to the
information contained in my education records, including but not limited to the following (please check to indicate which records
you are providing consent to release):
□ Academic (i.e., enrollment, grades, student schedule, academic transcript)
□ Non-Academic (i.e., student financial account, financial aid, scholarships)
I authorize release of the above records to the following party or parties:
1. Name: ______________________________________________________ email: _________________________________
2. Name: ______________________________________________________ email: _________________________________
Student Signature*:____________________________________________________ Date________________________
* This form MUST be notarized, or signed in the presence of an appropriate College staff member (Office of the Registrar, Financial
Aid, Admissions, or Site Coordinators, etc.) after presenting official photo identification.
Revocation of Consent to Release
Understanding my privacy rights under FERPA, I revoke my consent to permit a specific third party access to the information
contained in my education records. I understand that a revocation of access does not apply to information being sought through a
lawfully issued subpoena.
I revoke release of education records the following party or parties:
1. Name: ______________________________________________________ email: _________________________________
2. Name: ______________________________________________________ email: _________________________________
Student Signature*:____________________________________________________ Date________________________
*Signature is required.
Office of Registrar Use:
Date Received by Registrar: ___________________________________ Receiver’s Initials: ___________________
Office of the Registrar – FERPA CONSENT/REVOCATION FORM
2240 Iyannough Road │ West Barnstable, MA 02668
774.330.4711 │ Fax: 508.375.4084 │ registration@capecod.edu │ www.capecod.edu
