Family Educational Rights and Privacy Act
Please return completed form to the Registrar’s Office: AS-Registrar@Asnuntuck.edu
Last Name: _____________________ First Name: _________________Student Banner ID#: __________________
Address: ______________________________________________________________________________________
I authorize (specify department name, individual, or Asnuntuck Community College)
to disclose my educational records to the person(s) I have identified below for the purpose of supporting my academic
progress and/or coordination of disability services.
I have initialed below the categories of information that may be disclosed.
______ Financial ______ Disability Services
______ Financial Aid ______ Career/Vocational
______ Educational ______ Other: (please specify)______________________________
You may release these records and information to:
Parents/Guardian name(s): _________________________________________________________________
Department of Bureau of Rehabilitation Services: _______________________________________________
Another College: Name: ___________________________________________________________________
High School: Name: ______________________________________________________________________
Other: (specify) __________________________________________________________________________
I understand further that: (1) I have the right not to consent to the release of my education records; and (2) that this
consent shall remain in effect until revoked by me, in writing, but that any such revocation shall not affect disclosures
made by Asnuntuck Community College prior to the receipt of any such written revocation.
____________________________ ______________________________
Student’s Signature Date
Notice of Non-discrimination: Asnuntuck Community College does not discriminate on the basis of race, color, religious creed, age, sex, national origin, marital
status, ancestry, present or past history of mental disorder, learning disability or physical disability, sexual orientation, gender identity and expression or genetic
information in its programs and activities. In addition, the College does not discriminate in employment on the basis of veteran status or criminal record. The following
individuals have been designated to handle inquiries regarding the non-discrimination policies: Timothy St. James, Interim Dean of Students/Title IX Deputy,
0) 253-3011 and Deborah Kosior, 504/ADA Coordinator, AS-DisabilityServices@asnuntuck.edu (860) 253-3005, Asnuntuck Community College, 170 Elm
Street, Enfield, CT 06082.
Políticas Antidiscriminatorias: Asnuntuck Co
mmunity College no discrimina por razones de raza, color, creencias religiosas, edad, género, nacionalidad, estado civil,
ascendencia, historia presente o pasada de discapacidad mental o física, problemas de aprendizaje, orientación sexual, Identidad y expresión denero, o información
genética, en sus programas o actividades. Adicionalmente Asnuntuck no discrimina individuos por razones pertinentes a la categoría de veteranos o historia criminal. Las
siguientes personas han sido designadas para resolver cualquier inquietud pertinente a las políticas antidiscriminatorias: YTimothy St. James, Interim Dean of
Students/Title IX Deputy, tstjames@asnuntuck.edu (860) 253-3011 and Deborah Kosior, 504/ADA Coordinator, dkosior@asnuntuck.edu (860) 253-3005, Asnuntuck
Community College, 170 Elm Street, Enfield, CT 06082.
Rev.November 2020
NOTE: This document, when completed by the student, authorizes, but does not require, the College to disclose personally
identifiable information pertaining to the student that is maintained in College records. The College reserves its right
under federal law to decline to disclose such information when, in the exercise of the College’s judgment, it determines it is
not appropriate to disclose such information.