tudent ID#: ___________________ Email: _________________________________ Phone: _____________________
Last Name: _______________________________First Name: _______________________ Middle Initial: __________
Who is designated as your CCCC reference?
mail: ___________________________________________ Phone: __________________________________________
If student does not waive rights, provide an original copy of any reference to the student. A copy of each reference letter must also be maintained in
the student’s educational files or in your (the reference) files. You must also submit this Reference Request Form to the Office of the Registrar.
ERRPA Consent to Release
Academic and/or Personal Information to Third Party
In accordance with the Family Educational Rights and Privacy Act (FERPA), I authorize the above-named individual to
release my academic and/or personal information and provide an honest evaluation of my qualifications. This
evaluation can be based upon my involvement in activities or organizations outside the classroom or my performance
in their class(es) as well as my overall academic performance or participation.
his reference is for the purpose of:
□ Application for Higher Education
□ Other (please specify): ___________________________________________________________________________
I authorize reference information to be sent/released to the following party or parties:
□ I waive my right to review at this time or at any time in the future a copy of any letter submitted on my behalf to
the above party or parties.
□ I do not waive my right to review a copy of any letter submitted on my behalf to the above party or parties.
Student Signature*:____________________________________________________ Date________________________
*Form must be signed in the presence of a College official. The student must provide photo identification.
Office of Registrar Use:
Date Received by Registrar: ___________________________________ Receiver’s Initials: ___________________
Office of the Registrar – REFERENCE REQUEST FORM
2240 Iyannough Road │ West Barnstable, MA 02668
774.330.4711 │ Fax: 508.375.4084 │ firstname.lastname@example.org │ www.capecod.edu