Student's name *

First Name

Last Name

Student's date of birth *

MM

DD

YYYY

Active student or previous student? *

Active student

Previous student

Requester's Information

Requester * Student Other (Complete fields below)

Requester's name *

First Name

Last Name

Requester's phone number *

(###)

###

####

Requester's email *

Records Release Information

Records to be released *

Check all that apply

Attendance Records

Class schedule

Enrollment Verification Letter

GED Score

IEP

Immunization Records

Official Transcript (Can only be picked up or mailed out)

Progress Notes

Withdrawal Form

Other (Complete field below)

Other records to be released:

Purpose of release: *

Delivery of Records

How would you like to receive your request? *

Email

Fax (Complete field below)

Mail out (Complete field below)

Pick up

Fax number

(###)

###

####

Mailing Address

Mailing Address

Additional information:

i.e. Please include any additional information necessary to complete this request.