SAMPLE
XYZ Charter
719
555/555-1234
STUDENT RECORD RELEASE AUTHORIZATION
The XYZ Charter application provides for the exclusion of an applicant who has a documented history of criminal offenses, juvenile court adjudication or discipline problems under the TEC, Chapter 37. Final enrollment is based on a review of behavior records.
With this understanding, I, ____________________, give ________________ permission to
Parent or guardian Prior school
release any and all discipline records regarding ______________________ standing
Student name
concerning criminal offenses, juvenile
court adjudication, and any problems under the
Education Code, Chapter 37.
Student Name __________________________ Parent Name__________________________
Parent Signature ____________________________ Date _____________________________
(Acknowledgement)
STATE OF
BEFORE ME, the undersigned Notary Public, on this _____day of ___________, 20__, personally appeared_________________________, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she has executed the same for the purposes and considerations therein expressed.
____________________________________
Notary
Public-State of
Print
Name:_______________________
II. 10