Student Records Release Form printable pdf download

STUDENT RECORDS RELEASE FORM

Authorization for Release of Records Affidavit

LEASE OF RECORDS AFFIDAVIT

**Form must be notarized and ID must be attached**

Please place copy of

All Georgia Cyber Academy student educational records are

considered confidential in accordance with the Family Educational

Parent/Guardian

Rights and Privacy Act of 1974. Parents/Students 18 or older must

provide written, notarized consent to authorize the release of any

Driver’s License here

educational records information to self or third party.

Student license ONLY if student is 18 or older

I understand that if my student is 18 or older, that he/she must

request his/her own student information. I hereby consent to and

authorize the release of the following information:

Student’s First Name: ___________________________ Student’s Last Name: ___________________________ Grade Level: _____

Student’s DOB: _____________ GCA Student ID#: _____________ Year of Graduation

: ______________

(High School Students ONLY)

Purpose of the records release: __________________________________________________________________________________

(Examples: For parent record, applying to another school, transferring to another school, GED, etc.)

Please

myself/my student from Georgia Cyber Academy as of Date: ____ | ____ | _______

WITHDRAW

Requesting records for next school year/Applying to another school-

DO NOT WITHDRAW

Transferring to a Public/Private school: __________________________________________Date Enrolled: ____ | ____ | _______

(Circle One)

(Name of the Public/Private school)

I, ______________________________________________the parent/self of above student, request the release of my/his/her records.

(Print Name)

(Circle One)

Please release records to me/on my behalf as indicated below:

**********************PLEASE PRINT **********************

Name: ______________________________________________________

Office/Attention: _____________________________________________

Notary Seal Here

Street Address: _______________________________________________

City, State Zip Code: __________________________________________

Daytime Telephone Number: (

) ____________________________

E-mail: _____________________________________________________

(Please print carefully)

Fax Number: _________________________________________________

Notary Signature: ______________________

(Please ensure that you have provided correct fax number)

Parent/Student (only if 18+) Print Name:

_____________________________________

Today’s Date:

Parent/Student (only if 18+) Signature:

_______________________________________

____ | ____ | _______

Please Note: Processing time is 7-10 business days

ffffffffffffffffffffPlease Mail, Fax, or E-mail the completed form

to:ffffffffffffffffffffff

For Special Education Records:

For K-8 General Education Records:

For 9-12 General Education Records:

Attn: Special Education Records Dept.

Attn: K-8

Attn: High School Records Dept.

Grade Records Dept.

1745 Phoenix Blvd. Suite 100 Atlanta, GA 30349

Fax #: 404-424-8984

Fax #: 877-890-5486

Fax #: 404-684-8830

E-mail:

For Office Use Only:

Date Received: ______________ Records Released By: ______________ Date Released: ______________

Student Records Release Form

Related Articles

Related forms

Related Categories