SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

361/555-1234

STUDENT RECORD RELEASE AUTHORIZATION

Date: _______________________________

Student ______________________________ Birth Date ___________________ Grade ____________

has my consent to release the following

(Name of Previous School)

information on the above named student to the XYZ Charter School.

Grades, including withdrawal grades

Date of entry/withdrawal from your school

Test records/achievement scores

Key to grading system

Home language survey

Health data/immunization records

Other information that would be helpful in working with this student

Signature ______________________________Relationship to Student __________________

Date Enrolled

Name and Address of Previous School____________________________________________

___________________________________________________________________________

___________________________________________________________________________

NOTE TO SENDING SCHOOL: PLEASE FORWARD RECORDS TO ABOVE ADDRESS TO THE ATTENTION OF THE SCHOOL COUNSELOR.

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