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ARE YOU BORN BEFORE 1975 OR A GOSHEN COMMUNITY SCHOOLS EMPLOYEE LOOKING FOR IMMUNIZATIONS?
*
YES
NO
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IF NO, go back to the Goshen Community Schools website and use the link for Transcript Request
That link will allow you to request your school information.
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7330 F4
CONSENT FOR STUDENT RECORD RELEASE
STUDENT:
*
BIRTHDATE:
*
Years attended GCS:
*
Graduated:
*
YES
NO
If you did graduate, what year did you graduate?
A. You are authorized to release the records listed below for the above-named student to: (if self, give own name and address)
Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
B. Specific Data to be released: (Please check)
All personally-identifiable data on file.
School Transcript
Immunization Records
The following records only: (specify)
C. Reason for request: (Please check)
To aid in present and future educational decisions.
To aid in present and future employment
Legal Purposes (i.e.. custody, immigrant process...)
Personal Records
Other: (specify)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(Signature of parent/guardian/student*) (*Student must be 18 years old or older)
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