Roosevelt High School 1120 Nehoa Street, Honolulu, Hawaii 96822 (808) 307-0500 Fax: (808) 587-4648
Request for Student Records
Print full legal name used as a student at Roosevelt High School:
Last Name First Name Middle Initial(s)
Date of Birth: / / Graduation Year: ____
Month Day Year (If left RHS before graduation, list date/year released)
I hereby give consent for the transfer of academic records (check one):
Transcript (courses/marks) and unofficial college admission test scores (does not include PSAT)
Transcript (courses/marks) only. Include marks up through: (Circle One)
Qtr 2
Qtr 3
Qtr 4
Other Records (specify):
Select which copy option below: (You may select both options if requesting more than one transcript)
For Unofficial/Personal Copy* Amt. ____
For Official Copy (Signed & school seal embossed) Amt. ____
Select Transfer option:
(copy of picture ID must accompany request)
To be picked up by Requestor or indicate
name: __
Fax Number: _______________
eMail: ___________________________
Mailing Address:
*Not signed and not seal embossed. The
word “Unofficial” will be on the transcript.
Official Transcripts are mailed via USPS directly from Roosevelt High
Please complete Name and Mailing Address of school or organization
to receive transcript/records.
(If more space is needed, use back of form.)
If you have more names/addresses you are sending transcripts to, be
sure to provide name/address on back. Circle arrows for us to check
on the back:
Process Type (Please complete)
Cost per Record
# of Records
Subtotal Cost
Processing Fee for each Record (Allow 2-5 working days to leave
our office)
$1.00 per record
Global Processing Fee (For Transcripts sent outside of United
States) - Need to provide envelope w/correct postage
$1.00 per record
Expedite/RUSH Fee (For Transcripts within the US Only)
(OR Same Day, Carry Out Service or Mailed Same Day, if received by
$5.00 per record
Date of Request: Requestor’s Phone Number:
Signature of Student (18 yrs or older) Signature of Parent/Guardian (If student is under 18 yrs old)
click to sign
click to edit
click to sign
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