Student Records Request Form
Requestor Information
Name
*
First Name
Last Name
Email
*
example@example.com
School Name
*
Student Information
Student Name
*
First Name
Last Name
Notes
0/100
Date of Birth
*
-
Month
-
Day
Year
Date
Last Grade Attended
*
Documents Requested
*
Transcripts
Test Scores
Immunization Record
Withdrawal Forms
Attendance Record
Discipline
Other
File Upload
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Certification Statement
INITIALS Authorization Certification: My initials herein certify and verify that I, as a representative of a school district, charter school, or private school compliant with Public Law 93-380, Educational Rights and Privacy Act, have express need to request this student's information from this Mojave Unified School District for the purpose of completing the cumulative record of a student that has enrolled within the school district, charter school, or private school that I represent. I understand that I, as the recipient of the record(s) agree to use said document(s) for legitimate interests only and that the information contained therein shall not be further transferred or communicated to any other unauthorized person or agency, whether inside or outside of the school district, charter school, or private school that I represent without the expressed written consent of the or guardian of the student, except under authority of Public Law 93-380, Educational Rights and Privacy Act. I certify this information as complete and accurate to the best of my knowledge. I understand that an incomplete request form will not be processed and will be considered closed after expiration of the 30 day notification window. I declare under penalty of perjury that the foregoing is true and correct.
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