REQUEST FOR PERMISSION TO RELEASE

PERMANENT SCHOOL RECORD TO THIRD PARTY

Name (at graduation/withdrawal): _____________________________________________

Year of Graduation/Withdrawal: ____________

Date of Birth: _____________________________

Social Security Number: ____________________

Current Address:_____________________________________________________________

____________________________________________________________

____________________________________________________________

Phone: ( )___________________

I hereby authorize the release of my complete academic record including courses taken, credits given and grades received. Standardized test scores, extracurricular activities, positions held and/or honors will also be included. The following information will be released only if initialed below:

____ Comprehensive Evaluation Reports

____ Individualized Education Program

____ Other: _________________________________________________________

Forward the information specified above to the following:

Name & Address:____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Name & Address:____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

________________________________________________ ____________________

Signature Date

Note: If the student is under age 18, a parent/guardian must sign. A $2.00 fee is assessed per transcript for individuals not currently enrolled in the Selinsgrove Area School District.

Date Sent: $2.00 Fee/Transcript: Initials: