Date request faxed or mailed: _____________________________
Date copies received: ___________________________________
PLAIN LOCAL SCHOOL DISTRICT [IRN: 049932]
Parent/Guardian/Student Consent for Records Release
TO Name of Last School Attended: REGARDING Name of Student:
_______________________________________ ________________________________________
ADDRESS STUDENT’S
of SCHOOL: ____________________________ BIRTHDATE: ____________________________
CITY/ST/ZIP: ____________________________ GRADE: ____________________________
The above named student has enrolled at GlenOak High School and we are requesting the following
information be sent to us:
*Grades in Progress *Health Record *Testing Data
*Report Card *Special Education Data *IEP/ETR
*Psychological Team Report *Transcript *Gifted Records
*ELL reports and test results *9
th
Grade Test Scores *Birth Certificate
Please send to:
With the understanding that the district cannot assume responsibility for the confidentiality of educational
information disclosed, I authorize you to release education information regarding the student named above, in
the manner indicated.
DATE: _____________________________ ____________________________________________
Signature of Parent
____________________________________________
Address
____________________________________________
City/State/Zip
NOTE: According to the Family Education Rights and Privacy Act [Buckely Amendment 99.31.P.L. 93-
380] dated 6/17/76, Vol.41 No. 118 Page 24673, parental permission is no longer required when records
are requested by authorized school personnel.