Request for Non-Disclosure of Directory Information
Asnuntuck Community College - Registrar’s Office
Email: AS-Registrar@Asnuntuck.edu
Under the provisions of the Family Education Rights and Privacy Act (FERPA), you have the right to
withhold the disclosure of any or all of the “Directory Information” listed below.
• Name
• Address
• Dates of Attendance
• Full/Part-time status
• Major/ Program of study
• Graduation Dates
• Awards & Honors
A
CC will honor your request to withhold Directory Information but cannot assume responsibility to contact you for
subsequent permission to later release your records (i.e., pre-employment educational verifications). The institution
assumes no liability for honoring your instructions that such information be withheld.
L
ast Name: ________________________ First Name:___________________ MI:__ Student ID________________
I hereby exercise my right under FERPA to refuse to permit Asnuntuck Community College to release my
directory information unless specifically requested by me on a FERPA Release Form.
____
______________________________________________________ ________________________
Student’s Signature Date
R
egistrar’s Office Use Only
D
ate Received: ________________________
SPAPERS Updated on ___________________ by _________________________________
Date Staff Signature
O
riginal: Student File Copy: Dean of Students Copy: ______________________
Indicate Office
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: Yhara Zelinka, Title IX Coordinator,
yzelinka@asnuntuck.edu
(860) 253-3092 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 Community 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 de género, 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: Yhara Zelinka,
Title IX Coordinator, yzelinka@asnuntuck.edu (860) 253-3092 and Deborah Kosior, 504/ADA Coordinator, AS-DisabilityServices@asnuntuck.edu (860) 253-3005,
Asnuntuck Community College, 170 Elm Street, Enfield, CT 06082. April 2020
Should you decide to inform ACC not to release this
information, any future requests for such information from
those outside ACC will be refused. Information may be shared
with individuals considered “school officials” and others in
limited special circumstances. See the FERPA policy within the
ACC catalog for full details.
