Records Request UTOPIAN ACADEMY FOR THE ARTS

REQUEST AND AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
UTOPIAN ACADEMY FOR THE ARTS
STUDENT INFORMATION
Name *

Legal First Name Legal Middle Name Legal Last Name Suffix
Grade *
Gender
Birth Date *

Month Day Year
Date
Last 4 of Social Security Number/ Student Number
Home Address *
City *
Zip *
Phone: (including area code): *

Area Code Phone Number
SCHOOL RECORDS ARE REQUESTED FROM
Name of School *
School Address
City *
State *
Zip Code
Phone: (including area code) *

Area Code Phone Number
Fax Number: (including area code)
RECORDS TO BE RELEASED

Authorization to release the following information:
Cumulative record including grades and attendance

Report Cards with current grade averages and academic transcript

Immunization and health/medical records

Standardized test scores

Discipline Records

Special placement records and reports (including IEP, EIP, Speech, 504Plan)
Other (Specify)
RELEASE SCHOOL RECORDS TO
SELECT ONE: *

Utopian Academy for the Arts- Elementary School 2750 Forest Parkway, Ellenwood, GA 30294 Utopian Academy for the Arts- Middle School 2750 Forest Parkway, Ellenwood, GA 30294
Please send documents to:

FAX: (770) 234-6707
PARENT/LEGAL GUARDIAN SIGNATURE
I, the parent/legal guardian of the above named student, hereby authorize the above named school to release any of the listed school records to Utopian Academy for the Arts. This request shall serve also serves as notification that the above-listed student is now enrolled in Utopian Academy for the Arts. All information obtained will be treated in a confidential manner by Utopian Academy for the Arts under the provisions of the Family Education Rights and Privacy Act (FERPA).
Parent/Legal Guardian Name *
Parent/Legal Guardian Signature: (Required) *

Clear
Relationship to Student *
Date *

Month Day Year
Date
* Per Ga DOE Board Rule 160-5-1-14 schools must main or otherwise deliver requested records within te (10) calendar days of receipt of request. Schools shall NOT withhold any student record due to non-payment of fees Georgia requires that all students entering Georgia schools for the first time, regardless of grade level, provide a shot record (immunization) record showing that they are adequately immunized. Please include this immunization record in your release, if available. Elementary School Registrar- A. Thomas; albert.thomas@utopianacademy.com Middle School Registrar- A. Calvin; angelic.calvin@utopianacademy.com
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REQUEST AND AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

UTOPIAN ACADEMY FOR THE ARTS

STUDENT INFORMATION

SCHOOL RECORDS ARE REQUESTED FROM

RECORDS TO BE RELEASED

RELEASE SCHOOL RECORDS TO

Please send documents to:

PARENT/LEGAL GUARDIAN SIGNATURE