School Release Form (Page 2 of 2) in pdf

School Release Form Page 2

REQUEST FOR LIMITED ADULT

CRIMINAL HISTORY INFORMATION

Please print all information

First Name:___________________________________________________

Last Name:______________________________Middle____________________

Maiden Name:_____________________________________________________

Nickname (if applicable):_____________________________________________

Date of Birth:______________________________ Sex:____________________

Race:_____________________________________________________________

(A-Asian/Pacific; W-White; I-American Indian/Alaskan; B-Black; M-Multi-Racial; U-Unknown)

Address:___________________________________________________________

City:______________________________________ State:_________ Zip:_______

Social Security #:_____________________________________________________

Signature________________________________________Date:_______________

Mission Statement: “Christ First, Academics Second to None”

It shall be the policy of the school, to admit students of any race, color, gender, national or ethnic origin to all the rights, privileges,

programs and activities accorded or made available by the school. The school shall not discriminate on the basis of race, color,

gender, national or ethnic origin in administration of its educational policies, scholarship and loan programs, admission policies, and

athletic and other School Administered programs

School Release Form Page 2