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Transcript Request

This document is a request form for the release of student records from Lima City Schools. It provides information about a student, including name, date of birth, address, and the last school attended. The form specifies the type of records being requested, such as academic work, tests, health records, and personal identifiable data. It also indicates where the requested records should be sent. Signatures are required from a school official and the parent/guardian or student to authorize the release of educational information.

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SpartanSpirit
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© Attribution Non-Commercial (BY-NC)
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Download as PDF, TXT or read online on Scribd
1K views

Transcript Request

This document is a request form for the release of student records from Lima City Schools. It provides information about a student, including name, date of birth, address, and the last school attended. The form specifies the type of records being requested, such as academic work, tests, health records, and personal identifiable data. It also indicates where the requested records should be sent. Signatures are required from a school official and the parent/guardian or student to authorize the release of educational information.

Uploaded by

SpartanSpirit
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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LIMA CITY SCHOOLS

DR. EARL A. McGOVERN EDUCATION WING


755 ST. JOHNS AVENUE
LIMA, OH 45804

REQUEST FOR RELEASE OF RECORDS

I hereby authorize the release of records for:


Student Name:________________________________________________________________
Last Name

Maiden Name

First Name

M.I.

Present Address:______________________________________________________________
Street

Date of Birth:_________________

City

State

Zip

Age:____________ SS#:__________________________

School last attended:___________________________________________

Grade:_______

Last Year of Attendance or Graduation Date:________________________


Reason Requested: ______I have moved to ___________________________School District
______I have Open Enrolled to _____________________School District
______College/Employment/Other:____________________________
Please release/send the following records:
_____Academic Work/Transcript
_____ALL Tests/Scores/Evaluations
_____Psychological Reports
_____Health/Immunization Records/Attendance
_____Personal Identifiable Data [includes birth certificate, SS, Limited English]
Please send requested information to:
________________________________

Attn:___________________________

School/Business

________________________________

________________________________

Address

City, State, Zip Code

________________________________

________________________________

Phone

Fax

I understand that the district cannot assume responsibility for the confidentiality of educational information disclosed. I authorize you to
release educational information regarding the student named above in the manner indicated:
_____________________________________________________
School Officials Signature
Date

_____________________________________________________
Parent/Guardian/*Students Signature
Date
*Student must be 18 years of age to sign

FOR OFFICE USE ONLY:


Date Data Released:______________________By:_________________________________________
Date Copies Mailed:_____________________ By:_________________________________________
Last Lima City School Attended:___________________________Incoming Grade Level____________

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