SOUTHWESTERN ACADEMY
REQUEST FOR RELEASE OF ACADEMIC RECORDS
San Marino, California, and Rimrock, Arizona
STUDENT'S NAME (While Attending):
Last date of attendance:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Address:
City / State or Country / Postal Code:
Your E-mail address:
example@example.com
PLEASE GIVE COMPLETE ADDRESSES FOR EACH COPY REQUESTED.
1) NAME OF SCHOOL:
School's Email Address::
example@example.com
USPS: ADDRESS:
CITY: STATE: ZIP:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2) NAME OF SCHOOL:
School's Email Address::
example@example.com
USPS: ADDRESS:
CITY: STATE: ZIP:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3) NAME OF SCHOOL:
Email
example@example.com
School's Email Address::
example@example.com
USPS: ADDRESS:
CITY: STATE: ZIP:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
The transcript MUST be signed by the person listed above if student is 18 years of age or older, A parent must sign if the student is under 18 years of age and no longer attending Southwestern Academy. I give my permission to Southwestern Academy to release my school records.
Signature of student if 18 and over; or of parent
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
COST:
There is a processing fee of
$5.00 per copy
for students no longer enrolled at Southwestern. Transcripts will be mailed via the United States Postal Service. Special handling will require extra payment based upon cost of delivery fees.
RETURN THIS FORM AND FEE TO:
SOUTHWESTERN ACADEMY
Records Office,
2800 Monterey Road
San Marino, California 91108
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