2025-26 NON DIA RECORDS REQUEST

NON DIA RECORDS REQUEST
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Current Grade*
Last 4 of student Social Security Number*
Last school attended
Student was:*

PromotedPlacedRetainedNot Applicable
Current Mailing Address of Parent/ Guardian

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Email Address*
example@example.com
Current Phone Number*
Please enter a valid phone number.
Parent/ Guardian Signature*

Clear
Parent/ Guardian ID*

Cancelof
Please have records sent to:

DuBois Integrity Academy, Inc.

Administrative Office

6504 Church Street, Ste. 1&2

Riverdale, Georgia 30274

770.629.1534 (Office)

678.489.3866 (Fax)
Should be Empty: