Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Request to Withhold Directory Information (FERPA)
In compliance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the College may disclose information about a
student if it is designated as “directory information.” The following information has been designated as directory information by the
College and may be released to the general public and military recruiters (per the Solomon Amendment) without student
authorization;
Name
Address
Phone number
Student campus email address
Date(s) of attendance
Enrollment status
Date of Birth
Major field of study
Honors and awards
Graduation and degrees awarded
Credit hours earned
You have the right to withhold the disclosure of directory information. The failure of any student to specifically object to the release of
information listed above within fourteen days following the first day of classes will be interpreted as approval. Requests objecting to the
release of information must be made utilizing this form.
By completing this form, you will be requesting the College not release information from your student record without your written
permission. This request can be withdrawn at any time. This request will expire upon graduation from the College.
The complete Student Records policy can be found in the College Catalog; http://catalog.sunyacc.edu/regulations/studentrecords
Student Acknowledgment of Student Records Policy and Limitations:
Semester: ☐ Summer ☐ Fall ☐ Winter ☐ Spring Year: ______________
Student Banner ID: _____________________________________
Student Name (Please print): ______________________________________________________________________________
First Middle Last
I have read the College’s policy on the release of student records. This request only applies to student records and does not apply to
College employment records. I am requesting that my student records be withheld from the public except where required by law.
I understand that by withholding directory information this does not prevent the disclosure of personally identifiable information to
authorized representatives of federal, state, and local agencies, or any of the other exceptions to signed consent found in FERPA
regulations. The College works with the National Clearinghouse and my information will continue to be released to them. Authorized
individuals at the College and whom I have granted access to via the FERPA Waiver Authentication Survey will be able to receive
information. Information will still be released to comply with a judicial order or lawfully executed subpoena.
The College will not publish any information regarding academic awards, scholarships or graduation. I understand it is my responsibility
to provide authorization for the College to follow through on any verifications or certifications.
I understand that this request can be rescinded by at any time by updating the form below or notifying the Registrar in writing.
Student Signature: _____________________________________________________________ Date: _______________________
Completed forms must be submitted to the Office of Records and Registration via mail or in person with original signatures.
Forms must be submitted within fourteen days following the first day of classes for the semester listed above.
Request forms will be processed within 3 business days after receipt of the completed form.
Student Request to Cancel Withholding of Directory Information:
I am requesting to cancel my previous withholding request. My directory information can be released in accordance with College policy.
Student Signature: _____________________________________________________________ Date: _______________________
For Registrar Use to Withhold Directory Information: Initials: _____________ Date Processed: _____________
For Registrar Use to Cancel Withholding of Directory Information: Initials: _____________ Date Processed: _____________
Updated: 7/24/19
