Student Record Release Form

Student Record Release Form

Michigan Conference of Seventh-day Adventist Education System
This form grants Grand Rapids Adventist Academy permission to request a copy of your child's most recent report card, recent transcript, or a copy of your child's IEP.
Name of School of Last Attendance: *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Authorization

I hereby authorize ___________________________________(name of school, see above line), to send a copy of HS transcript, elementary report card for last grade/semester completed, latest standardized test results, grades to date, ESL assessments, 504, IEP, or other documented accommodations and any information regarding behavior to: Grand Rapids Adventist Academy 1151 Oakleigh Rd NW Grand Rapids, MI 49504 or fax to 616.791.7242, or emailed to tmattzela@graa.com.
Parents/Guardian Name *

First Name Last Name
Today's Date

Month Day Year
Date
Parent/Guardian Signature *

Clear
Should be Empty:

This form grants Grand Rapids Adventist Academy permission to request a copy of your child's most recent report card, recent transcript, or a copy of your child's IEP.