Request for Transcripts and Student Records
Student Name (Last, First Middle)
Birth Date
Grade
School Attended
School Address
City, State Zip
Telephone
Fax
I AM REQUESTING THE FOLLOWING RECORDS:
_____ACADEMIC TRANSCRIPT/TEST SCORES, ATTENDANCE
RECORDS _____HEALTH HISTORY, ACCIDENT AND HEALTH
RECORDS _____DISCIPLINARY INFORMATION
I authorize The Institute of Islamic Education to obtain information concerning the above named student.
Please mail my transcript/medical records to;
Attention: Main Office
The Institute of Islamic Education
12 80 Bluff City Blvd.
Elgin, IL 60120
Parent/Guardian Signature: ________________________________________________________
Date: _______________
Address _______________________________________________________________________________________________
City _________________________________________
State _____________ Zip _______________________