Sample Request For Release Of Student Records
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1Sample Letter: Request for Release of Student Records
Dear School Counselor/Registrar:
The children listed below have been withdrawn from your school. Please release their health, academic
and other records, and forward them to the receiving school, as noted below. Thank you for your
cooperation.
Name of Student/s
Last Name
First Name
Initial Age
Grade Level
Receiving School
________________________________
Name of School
_____________________________
Address
_____________________________
City, State, Zip
_____________________________
Phone number
Authorization
_________________________
Name of parent/guardian
___________________________
Address
___________________________
City, State, Zip
___________________________
Phone number
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