Record Release Form

RECORD RELEASE FORM

(LAST UPDATED 7/18/2022)
In order to forward or request school records to or from other schools, Centerville Christian School is required to obtain your written permission.
Child's Name

First Name Last Name
Child's Date of Birth
Records Kept by (name of school)
Address of School Where Records Are Kept

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

RECORD RELEASE PERMISSION
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 *

Clear
Date *

Month Day Year
Should be Empty:

RECORD RELEASE FORM