Record Request

REQUEST FOR STUDENT RECORDS

Mail to: __________________________________________

Date Mailed: ______________________________________

_________________________________________________
Name of School

_________________________________________________
Address

_________________________________________________
City                             State              Zip Code

* Present schools may be contacted to obtain any pertinent information
regarding any academic, social or behavioral difficulties.*

*Please send THE FOLLOWING RECORDS for the student(s) listed below:

_______ All available school records
_______ Grades
_______ Attendance
_______ Health & immunization records
_______ Copy of birth certificate
_______ Legal custody documentation
_______ Standardized achievement testing results
_______ Phychological reports
_______ Current I.E.P.
_______ Speech testing results
_______ Social security number

____________________________ Student's Name

_______ Grade

______________ Birthdate

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Note: It is not necessary for parents to sign a release when records are being passed from school to school. see
Federal Register June 17, 1976 Part II H. E. W. Privacy Rights to Parents & Students. Vol. 41.

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Parent's Signature _________________________________________________________

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