Student Education Request Form

STUDENT EDUCATION REQUEST FORM

Use this form to submit a formal request related to a student's educational records, program placement, services, or accommodations. Complete all applicable sections, attach supporting documentation, and sign the certification below. Incomplete requests will be returned and may delay processing.

Student Information

DOB:    Student ID:

Parent / Guardian (if student is under 18)

Is the student under 18 or otherwise legally represented?   Yes    No

Request Details

Select the type(s) of request (check all that apply):

Official Transcript    Enrollment Verification    Records Release    Special Education Evaluation Request

Accommodation/504 Plan Consultation    Course Change / Schedule Adjustment    Other (describe below)

Academic Transcript    Grades/Report Cards    Attendance Records    Discipline Records

Special Education / IEP Documents    Health / Immunization Records    Other Documentation (describe below)

Needed by (if applicable):

Supporting Documents

Administrative Terms, Authorization, and Certification

By signing below, the signing party authorizes the release or amendment of educational records as indicated above and certifies that the information provided is true and complete to the best of their knowledge. The signing party further authorizes the school or district to obtain and disclose records as necessary to fulfill this request and to communicate with designated recipients. This authorization is valid for the purpose stated and expires one year from the signature date unless an earlier expiration is specified: Expiration (optional):

Records requested for special education evaluation or placement will be processed in accordance with applicable law and internal procedures. Submission of this request does not guarantee immediate placement or services; additional evaluation or documentation may be required. The signing party acknowledges that certain records may be subject to redaction of information protected by third-party privacy rights.

Processing Fee Acknowledgment: Some requests, such as multiple official transcripts or expedited service, may incur fees. By checking the box below, the signing party acknowledges potential fees and agrees to pay applicable charges.

I acknowledge possible fees and agree to pay charges associated with this request.

Privacy Notice: Educational records are protected and will be handled confidentially. Information released pursuant to this request will be disclosed only to the named recipient(s) and only for the stated purpose. The school is not liable for subsequent disclosures by recipients.

Certification: I certify under penalty of perjury that I am the student named above or the parent/legal guardian or authorized representative of the student, and that I am authorized to make the request and sign this form.

Signature of Authorized Party

Indicate who will sign this form:   Student    Parent/Guardian    Authorized Representative

If signing as an authorized representative, describe authority (e.g., power of attorney, court order):

By signing, the signing party attests that they have read and understood the terms above, that the information provided is accurate, and that they consent to the release or processing of records as requested. If signing as a parent or guardian, the signer confirms legal authority to act on behalf of the student.

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