GlenOak High School
Request for Records/ Transcripts Form
Consent For Records (Transcripts) Release
Transcript Fee $3.00
Student’s Name___________________________________________________ (at time of graduation)
Please print clearly
Date of Birth __________________ Phone Number_________________________
Date of Graduation _________________ OR Date of Withdrawal _____________________
Complete Sections 1, 2 & 3
1. I authorize GlenOak High School personnel to release my records and information to:
___ Specific College or Scholarship Agency and include complete address
_____________________________________________________________
Name of college or agency
______________________________________________________________
Complete address (including zip code) of college or agency
OR
___ Mail it to my home address (listed below)
______________________________________________________________
OR
___ I wish to take my transcript with me.
2. Specific data to be released (please check all items to be released).
___ Transcript of grades and any other information required for college applications
(SAT, ACT test scores, etc.)
___ Transcript only
___ Other information _____________________________________________
3. Reason for this request: (please check one)
___ College Application/ Scholarship Application
___ Employment
___ Other
__________________________________ ____________________
Signature Required Date
Parent/guardian signature is needed
if student is under the age of 18)
