Request

Records Request

To be completed by Parent of Legal Guardian (please print)
Student's Full Name

First Name Last Name
Birth date: Date Current Grade:
School Transferring From:
Phone number:Area Code Phone Number email address: Email
School Adress

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
1. You are authorized to release the records listed below for the above named student to:
The CinDay Academy
11 Sycamore Creek Dr
Springboro, OH 45066
(P) 937.748.1991
(F) 937.748.2091
Email: Director@CinDayAcademy.com

2. Please release ALL records. This includes, but not limited to:
Grades
Attendance
Health Records
Standardized Test Scores
Psychological Evaluation
Evaluation Team Report
I.E.P.
Behavior/Correction Reports
Birth Certificate

3. This form gives CDA authorization to contact via email, phone or text the student’s current school and teacher(s) for additional information.
4. Reason for Request: (please check)

To aid in present and future educational decisions Enrolling in The CinDay Academy Other: (please state)
other:
Signature Signature Date
Should be Empty:

Records Request