Student ID#: ___________________ Date of Birth: ___________________
Last Name: ______________________________________ First Name: __________________________ Middle Initial: __________
Mailing Address: ____________________________________________________________________________________________
City: ____________________________________________________ State: _______________ Zip Code: _____________________
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), it is the policy of Cape Cod Community College
to release certain limited information about students to third parties that is considered public information. This information,
known as “directory information,” is defined by CCCC as the following:
• Name
• Town of Residence
• Student Email Address
• Program of Study
• Enrollment Status
• Dates of Attendance
• Withdrawals or Leaves
• Date of/or Anticipated Date of Graduation
• Degrees, Certificates, Honors, and/or Awards
Received
• Student Activities or Clubs
• Most Recently Attended Institution
• Photographic Image for Publications or
Announcements
No other items of student information will be released to any person or organizations outside of Cape Cod Community College
without the written consent of the student, except for certain categories of outside persons or organizations specifically exempt by
federal law. These exceptions are listed in the document “Cape Cod Community College Policy on the Confidentiality and
Disclosure of Information about Students” and bulletins available in the Registrar’s Office.
Under the provisions of FERPA, students have the right to instruct the College to withhold the directory information listed above to
third parties. A copy of this form must be completed, signed and received at the Registrar’s Office in order to instruct the College
to withhold directory information.
By signing below, I am requesting that Cape Cod Community College withhold my directory information. I have read this form
carefully and understand the consequences of my decision. I understand that:
• This prohibits Cape Cod Community College from acknowledging any information regarding my enrollment to any third
party including potential employers, loan deferments, insurance companies, and requests from non-institutional
persons/organizations.
• This does not prevent disclosure within classroom and learning environments including on-line components that I may
enroll in or participate in within the College.
• This does not prevent disclosure to personnel within the College, or its agents, or a lawfully issued subpoena, or in an
emergency situation as defined under FERPA or as applicable under state and federal laws.
• This suppresses my information from commencement programs, degree, honors and awards announcements.
• This request remains valid until I request in writing, with signature and ID, that it be revoked and that I must submit this
request to the Office of the Registrar.
• The College assumes no liability for honoring my instructions that this information be withheld.
Signature: ___________________________________________________ Date: ________________________________________
Office of Registrar Use:
Date Received by Registrar: ___________________________________ Receiver’s Initials: ___________________
Office of the Registrar – REQUEST TO WITHHOLD DIRECTORY
INFORMATION FORM
2240 Iyannough Road │ West Barnstable, MA 02668
774.330.4711
Fax: 508.375.4084
registration@capecod.edu
www.capecod.edu
