REQUEST FOR PERMISSION TO RELEASE

PERMANENT SCHOOL RECORD TO THIRD PARTY

Name at Graduation/Withdrawal:  _____________________________________________

(Please circle Graduation or Withdrawal)

Year of Graduation/Withdrawal:  ____________

Date of Birth:  ____/____/____     Last four digits of 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 (Special Education / Gifted)

                ____   Individualized Education Program  (Special Education / Gifted)

                ____   Other:  _________________________________________________________

Forward the information specified above to the following:  (Attach a separate sheet or use back for more than 2.)

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.  Cash or money order, no personal checks.

For Office Use only: 

Amount Received:

Date Mailed:

Initials: