Record Release Form

School Record Release

Last updated: July 2025
In order to request school records from other schools, Centerville Christian School is required to obtain your written permission.
- Child's Name*
  
  First NameLast Name
- Child's Date of Birth*
- School Name
  Name of the school holding the applicant's records
- School Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- I hereby consent to the release of a copy of all records, which would include attendance records, transcripts, test results, IEP's, health and immunization records, grades to date of withdrawal, and any other information that might assist in placement and guidance. *
  
  Yes
- I understand that, pursuant to rights contained in the Family Education Rights and Privacy Act of 1974 any information released to Centerville Christian School will not be released to any other party without the written consent of the parents of the above named student, or the student if eighteen years of age. *
  
  Yes
- I understand that by completing the information my child's records will be released to Centerville Christian School.*
  
  Yes
- Signature*
- Date*
  
  MonthDayYear
- Should be Empty:

School Record Release