504.1F RELEASE OF STUDENT RECORDS FORM

504.1F RELEASE OF STUDENT RECORDS FORM

 

Release of Records:

 

DATE: _____________________

 

TO:      _____________________     Name and address of previous school,

           _____________________    Medical Facility or Social Services

           _____________________

           _____________________

      

REQUEST FOR TRANSCRIPT OF CREDITS/STUDENT INFORMATION RELEASE:

In accordance with the Family Educational Rights and Privacy Act 1994, I hereby authorize the release of all records and pertinent information regarding the below named student to:

                                 

GUIDANCE DEPARTMENT

                                 GLENWOOD COMMUNITY HIGH SCHOOL

                                 504 E. Sharp Street

                                 GLENWOOD, IOWA  51534

 

STUDENT’S NAME: ___________________________________________________

GRADE IN SCHOOL: ___________________________________________________

BIRTH DATE: _________________________________________________________

                                  ______________________________DATE:__________

                                 SIGNATURE OF PARENT OR GUARDIAN/or

                                 SIGNATURE OF STUDENT IF OVER AGE 18

 

PLEASE INCLUDE:

____ TRANSCRIPTS/REPORT CARDS           ____PSYCHOLOCIAL RECORDS       

____ IMMUNIZATION RECORDS                    ____ CURRENT COURSES AND GRADES     

____SOCIOLOGICAL RECORDS                    ____ SPECIAL EDUCATION RECORDS    

____KEY TO GRADING SYSTEM USED        ____TEST DATA/STANDARDIZED TESTING

____ HEALTH/MEDICAL RECORDS              ____ COPY OF BIRTH CERTIFICATE

____ ATTENDANCE RECORDS                    ____ DISCIPLINE RECORDS

 

*Adopted: 12/11/17

*Reviewed: 10/10/22