Release of Student Records Request-Pan American Academy Charter School

PAN AMERICAN ACADEMY CHARTER SCHOOL

Request and Authorization for Release of Student Records and Documentation
Student Information/Informacion del Estudiante

First Name/NombreMiddle Name/Segundo NombreLast Name/Apellido:
Gender/Genero:
Current Grade:
Birth Date/Fecha de Nacimiento:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does the student have an active IEP or 504 Plan, or are they currently receiving special education services?
I authorize Pan American Academy Charter School to--Autorizo a Pan American Academy Charter School a:
The PURPOSE of the release is for--El PROPÓSITO de la solicitud de registros es para:
Other (please note below)--Otros (tenga en cuenta a continuación):
Records/Documents to be released--Registros/Documentos que se publicarán
Other (please note below)--Otros (tenga en cuenta a continuación):
RELEASE SCHOOL RECORDS TO/ENTREGAR REGISTROS ESCOLARES A
Name of School/Person/Agency--Nombre de la Escuela/Personal/Agencia:
Phone Number/Número de Teléfono:
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/LEGAL GUARDIAN SIGNATURE
I understand it will take up to FIVE business days to process my request.

FIRMA DEL PADRE/TUTOR LEGAL
Entiendo que el procesamiento de mi solicitud demorará hasta CINCO días hábiles.
Signature of Authorized Adult (Parent or Legal Guardian)--Firma del adulto autorizado (padre o tutor legal)
Relation to Student:
Current Address/Dirrecion:
City/State/Zip Code
Parent or Requester's E-Mail Address
example@example.com
Phone Number/Número de Teléfono:
Format: (000) 000-0000.
Date/Fecha

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PAN AMERICAN ACADEMY CHARTER SCHOOL