Student Records Release Form printable pdf download

4241 Summerhill Road • Texarkana, Texas 75503 • 903.794.3651 • fax 903.792.2632 •

student records release form

Party requesting records: ________________________________________________________________________

Phone numbers: Home:________________________________ Work: _________________________________

Full Name Of Student At Time Of Enrollment (Please Print)

First: _________________________ Middle: _________________________ Last: ________________________

Date of birth: ________________ Last grade attended: __________ Date of graduation/withdrawal: __________

Last TISD campus attended: _____________________________________________________________________

Type of records requested: (Transcript, enrollment, proof of birth, attendance,etc.)

____________________________________________________________________________________________

Reason for request of records: (College, Employment, ID Card, Driver’s License)

____________________________________________________________________________________________

Party to whom records are to be released:

❏ Self

❏ Parent/Guardian

❏ Other (name) ________________________________________________

Positive Photo ID, such as a Driver’s License Required for Records Release

Check release method:

❏ pick up

❏ mail

❏ fax number

Current Mailing Address Required For All Request Of Student Records Or Mail To Address Of College

Name: ______________________________________________________________________________________

Address: ____________________________________________________________________________________

City: ___________________________________________ State: ______________ Zip: __________________

I hereby give consent for the release of the records listed above.

Signed: ___________________________________________________________ Date: ____________________

Parent/Guardian or Eligible Student (Students under the age of 18 must have signature of parent/guardian)

For Office Use Only

ID Provided: _______________________________________ Request Date: ___________________________

Release Date: _______________________________________ Released By: ___________________________

Campus: _______________________________________________ Source: ___________________________

Student Records Release Form