Restriction of Disclosure of Directory Information
DIRECTORY INFORMATION: The Family Educational Rights and Privacy Act (FERPA) is a federal regulation that governs how
educational institutions collect and disseminate student records data. Washington State Community College may disclose on an
unlimited basis information that has been designated as Directory Information in response to oral or written requests.
Please restrict the publication and release of Directory Information from my Washington State Community College education
record. By completing this request, the disclosure of information to non-college parties will occur only with my written
permission and will restrict all of the items in the following list that have been designated as Directory Information by
Washington State Community College:
- Student’s Name
- Address
- Telephone listing
- Electronic mailing address
- Photograph
- Date and place of birth
- Major field of study
- Enrollment status (e.g. full-time or part-time)
- Participation in officially recognized activities
- Dates of attendance
- Degrees, honors, and awards received
- The most recent educational agency or institution
- Grade level
Note: Restricting your Directory Information will prevent information from appearing in College publications, such as the student
directory, the Commencement Program, and Dean’s/President’s List notifications; additionally, should the College receive any requests
from a future employer, childcare provider, reference, etc. we will not release any of the designated Directory Information.
____________________________________________ _____________________________________
Student Legal Name (Please Print) WSCC Student ID Number (Required)
____________________________________________ ____________________________________
Student Signature Date
Note: This restriction will be effective within two business days of its submission and I understand that I can revoke this
restriction at any time by retrieving this document from the Records Office and completing the Revocation of the Release section
below the dotted line.
Complete and Return this Request to: Washington State Community College, Records Office; mail to 710 Colegate Drive,
Marietta, Ohio 45750; fax 740-568-1965; email
Office Use Only: Processed by ______________________________________________ Date ___________________________
I acknowledge that by my signature below, I am cancelling the restriction of the publication and release of Directory Information. This restriction was
entered based on a previously submitted Request for Restriction of Disclosure of Directory Information (see above). This cancellation supercedes any
other prior requests concerning the release and disclosure of directory information from my student record.
_______________________________________________________ __________________________
Student Signature (Required) Date
Office Use Only: Processed by __________________________________________ Date ______________________________
Rev: 11/17/16
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