Records Request

Records Request

To be completed by Parent of Legal Guardian (please print)

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Student's Full Name

First Name Last Name
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Birth date: Date Current Grade:

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School Transferring From:
Phone number:Area Code Phone Number email address: Email

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School Adress

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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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: sboyle@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.

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4. Reason for Request: (please check)

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

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Should be Empty: