Student Record Release Authorization

10310 Dixie Highway, Florence, KY 41042 Phone: 859.371.9008 Fax: 859-371-5603
Name of Student *

First Name Last Name
Birth Date *

Month Day Year
Date
Grade *
Phone Number *
Student Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Records are held by: *
Name of School
Previous School Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Previous School Phone Number *
Please enter a valid phone number.
Fax Number *
Please enter a valid fax number.
The above-mentioned student is enrolled at Zion Christian Academy for the 2021-2022 school year. I, as parent/guardian of the above-mentioned child, authorize and approve the release of all information concerning the educational placement of my child.

This information should include:
- Grades
- Psychological Evaluation Reports
- Individual Standardized Achievement Test Results
- Health Records including Immunization Records, Physical Exams, Eye Exams
- Attendance and Discipline
- Please Send Portfolio Work if in the State of Kentucky
Records should be sent to:

Fax: 859.371.5603 Email: zionlions@zcaky.com
Parent or Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: