Student Education Request

STUDENT EDUCATION REQUEST

Request Date:

Student Information

Student Name:

Date of Birth:     Student ID:

Parent / Guardian Information

Type of Request (select all that apply)

Records release (educational records)
Enrollment / Program change
Special education evaluation / IEP services
Accommodation / 504 plan request
Transcript request
Course add/drop or schedule change
Graduation audit / diploma verification
Other (describe below)

Request-Specific Details

For Records Release — Records to be released:

For Enrollment / Program Change — Desired Program:    Requested Start Date:

Estimated Tuition / Fees:

Supporting documentation attached:

Academic Information

Emergency & Medical Information

Acknowledgements, Consents, and Certifications

By checking the box below and signing this form I certify under penalty of perjury that the information provided is true and complete to the best of my knowledge. I authorize the release, exchange or evaluation of the student’s education records as necessary to process this request, including but not limited to academic records, discipline records, health records, and evaluations. I understand that the school will use reasonable efforts to protect confidential information but cannot be held liable for disclosures made pursuant to this authorization and applicable law.

I understand that processing may take a reasonable period (typically up to 15 school days) and that additional documentation may be required. I acknowledge my responsibility for any fees or tuition obligations incurred as a result of program changes or enrollment, unless otherwise agreed in writing by the school.

I understand I may withdraw this request in writing, except to the extent actions have already been taken in reliance on this authorization. The school may rely on electronic or scanned signatures as original signatures for administrative processing.

Consent to Evaluate for Special Education: If requesting special education evaluation, I understand that the evaluation team will review existing records, conduct assessments as necessary, and that parental participation is required for eligibility determinations. I hereby give permission for the school to perform assessments as allowed by applicable law and policy.

Acknowledgement: I acknowledge and consent to the statements above.

Attachments

Supporting documents attached (check all that apply):
Academic records / transcripts
Medical documentation
Prior evaluations
Other supporting documents

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