High School Transcript Request Form Page 2

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Georgia Cyber Academy High School
Transcript Request Form for Colleges|Universities
Authorization for Release of Transcript Affidavit
** Driver’s License & PayPal receipt must be attached**
ECORDS AFFIDAVIT
Please place a copy of
All Georgia Cyber Academy student educational records are
Parent/Guardian
considered confidential in accordance with the Family Educational
Rights and Privacy Act of 1974. Parents/Students 18 or older must
Driver’s License here
provide written, notarized consent to authorize the release of any
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: ____ | ____ | _______
I have read the above statement and, pursuant to the law - I hereby authorize the release of a copy of the school transcript
to the following agency/institution named below:
**********************PLEASE PRINT **********************
1. Entity Name: _______________________________________________
2. Entity Name: _____________________________________________
Office/Attention: _______________________________________________
Office/Attention: _____________________________________________
Street Address: ________________________________________________
Street Address: ______________________________________________
City, State, Zip Code: ___________________________________________
City, State, Zip Code: __________________________________________
Phone Number: ________________________________________________
Phone Number: ______________________________________________
3. Entity Name: ______________________________________________
4. Entity Name: ____________________________________________
Office/Attention: _______________________________________________
Office/Attention: _____________________________________________
Street Address: ________________________________________________
Street Address: ______________________________________________
City, State, Zip Code: ___________________________________________
City, State, Zip Code: __________________________________________
Phone Number: ________________________________________________
Phone 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
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Please Mail, Fax, or E-mail the completed form
to:fgfg
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Attn: High School Records Dept.
1745 Phoenix Blvd. Suite 100 Atlanta, GA 30349
Fax #: 404-684-8830
E-mail:
For Office Use Only:
Date Received: ______________ Records Released By: ______________ Date Released: ______________

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