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