7330 F4
CONSENT FOR STUDENT RECORD RELEASE
STUDENT:
BIRTHDATE:
Year attended GCS:
Graduated:
YES
NO
if so, year graduated:
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
Date
(Signature of parent/guardian/student*) (*Student must be 18 years old or older)
Preview PDF
Submit
Should be Empty: