DC West Consent to Release Student Records

DC West High School
COMMUNITY SCHOOLS
PO Box 378Valley, NE 68064www.dcwest.orgPh: 402.359.2583 Fax: 402.359.4371
CONSENT TO RELEASE STUDENT RECORDS
Name
Grade Entering
Date of Birth

MonthDayYear
Date
I consent to the release of records from the student's current school:
SchoolOther
Street AddressPO Box
City State Zip
Phone Number
Format: (000) 000-0000.
FAX Number
Please include the following records:

*Transcript of credits and grades

-Interpretation of marking system

-Test scores/Assessments

-Evaluations/Reports

-Attendance Report

*Copy of Birth Certificate

*Health and Immunization Records

*Confidential psychological/SpED Records ( including IEP/MDT)

*Other information
Please fax records to: 402-359-2893 Attn: Counseling Center OR email to: nbilledeaux@dewest.org

Please send copies only (No cum folders)
Signature of ParentGuardian or Student if 18 years of age or older
Date

MonthDayYear
Date
Address City State Zip
Phone
Format: (000) 000-0000.
Should be Empty:

DC West High School