Release of Student Records Form

City of Boston

Archives and Records Management Division

201 Rivermoor Street, West Roxbury, MA 02132

Phone: 617-635-1195 ∙ Fax: 617-635-1194

e-mail: archives@boston.gov

http://www.boston.gov/archives
Consent for Dissemination of Student Records
Please indicate if the student record will be sent to YOU or to a THIRD PARTY*

MYSELF: I request to inspect or secure a copy of my own student transcript.THIRD PARTY: I give permission for the following third parties to inspect or secure a copy of my student transcript.
Student Information
Name of Student*

First NameLast Name
Alternate names used by student
Student's Date of Birth*

MonthDayYear
Name of School*
Please note the City Archives does not hold student records for those who graduated after the year 2000.

For records still in the custody of the Boston Public Schools, please click here to be directed to their online request form.
Year Student Left School*
please estimate if you are unsure
Did the student graduate?*

YESNOI'm not sure.
If student graduated, what year?
Additional notes for the City of Boston Archives staff:

Release Information to the Following THIRD PARTY:
Requestor's Information

First NameLast Name
Requestor's Email Address*
example@example.com
Third Party's Name (who the records should be sent to the attention to)*

First NameLast Name
Organization
Delivery Method*
Third Party Email Address
Third Party Fax

Area CodeFax Number
Third Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Release Information to MYSELF

If for a third party (such as a school or an employer), please check whether they will accept personal copies. Often the third party requires we send the copy directly to them.
Name*

First NameLast Name
Phone Number
Please enter a phone number where we might be able to reach you if we have questions about your request.
Email Address*
Delivery Method*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number

Area CodeFax Number

CONSENT
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Electronic Signature
Please electronically sign this form and sign your initials below
Initials*

Clear
Should be Empty:

Consent for Dissemination of Student Records