Fillable - Request For Release Of Student Records 12.14

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- Request For Release Of Student Records 12.14

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Achieve'Your'Dreams!'
2%8+%1&)9'3)2%$%"1%)'9)/&+4%(&)2%.'341)
Student!Name:!______________________________________!Birth!date:!__________________________!
Phone!#:!_____________________________________________!
Name!of!last!Mapleton!school!attended:!__________________________________________________!
Graduated:!YES!______!!!!NO!______!!Year:!________________!
2%.'341)"+&0'3-:%4)&'),%)3%$%"1%4),;)&0-1)3%8+%1&<)
All!available!records:!__________!
High!school!transcript:!_________!
Specific!records!listed!below:!!!
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________!
2%"1'()9'3)&0-1)3%8+%1&<)
Personal!use:!_______!
Sharing!of!relevant!educational!information!with!other!parties/agencies:!!_______!
Other:__________________________________________________________________________________________________!
*"3&;)'3)#"3&-%1)&')=0'6)&0-1)4-1.$'1+3%)6";),%)6"4%:!Please!include!the!n am e,!
address,!and!telephone!number!(also!the!fax!number!if!the!records!are!to!be!faxed)!of!the!
person(s)!and/or!institution(s)!granted!access!to!the!records!by!this!request:!
1. ___________________________________
___________________________________
___________________________________
2. ___________________________________
___________________________________
___________________________________
Method!by!which!these!records!are!to!be!released:!
To!be!mailed:!_______!To!be!faxed:!_________!Fax!#!____________________!Will!pick!up:!_______!
If!mailed,!please!list!ad dre ss:!________________________________________________________________________!
Address!! !!!!Apt.!#!! City!! !!!!!!!!!!!State!!!!!!!!!!!! !!!!!!!!!Zip!
>0%)#"3%(&?)$%@"$)@+"34-"(?)'3)%$-@-,$%)1&+4%(&)ABC);%"31)'9)"@%)'3)'$4%3D)-1)3%8+-3%4)&')
"+&0'3-:%)&0%)3%$%"1%)'9)1&+4%(&)3%.'341E)F9);'+)"3%)6"-$-(@G9"H-(@)&0-1)3%8+%1&?)
#$%"1%)3%6%6,%3)&')-(.$+4%)").'#;)'9)")I"$-4)F5)=-&0);'+3)1-@("&+3%)9'3)I%3-9-."&-'(E)
_______________________________________________________________! ________________________!
Signature!of!Parent,!Legal!Guardian,!or!Eligible!Student! Date!
(If$you$are$a$former$student$and$your$name$has$changed$since$you$left$$
school$please$sign$both$your$former$and$current$names.)$
Mapleton!Public!Schools!District!
Records!Department!
7350 N. Broadway
Denver,!CO!80221!
Phone:!303.853.1030!
Fax:!303.853.1091!
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Completed 21 July 2020

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