Name: Student ID:
In accordance with the Federal Educational Rights and Privacy Act of 1974 (FERPA), as amended, a student’s education
records are maintained as confidential by the College of the Siskiyous and, except for a limited number of special
circumstances listed in that law, will not be released to a third party without the student’s prior written consent. The law,
however, does allow the College to release student “directory information” without obtaining the prior consent of the
student. At the College of the Siskiyous we consider “directory information” to be those items of information listed below
in this Form. If you do not want the College to release your directory information without your prior consent, you may
choose to “opt-out” of this FERPA exception by signing the Form below. Directory information of a student who has
opted-out from the release of directory information, in accordance with this policy/procedure for opting out, will remain
flagged until the student requests that the flag be removed by completing and submitting the revocation section of this Form
to the College Registrar or until the student leaves the College.
TO: College of the Siskiyous Registrar
I request the withholding of the following personally-identifiable information that the College of the Siskiyous
has identified as Directory Information under FERPA. I understand that upon submission of this Form, the
information checked cannot be released to third parties without my written consent or unless the College is
required by law or permitted under FERPA to release such information without my prior written consent; and
that the checked directory information will not otherwise be released from the time the Registrar receives my
Form until the opt-out request is rescinded. I understand that I may not opt out of use of my student ID number
because it is necessary identifying information for the College. I further understand that if directory information
is released prior to the Registrar receiving my opt-out request, the College may not be able to stop the disclosure
of my directory information. I understand that I may request and challenge how my directory information is
used by contacting the Registrar’s Office at the College.
All information identified below
Student name
Mailing address
Class schedule
Student participation in officially recognized activities
Enrollment status (e.g. full-time or part-time)
Degrees and awards received by students, including honors, scholarship awards, athletic awards, and
President’s and Dean’s List recognition.
Student Signature: Date:
For Official Use Only
Form Received by SPACMNT Date: