School Records Request printable pdf download

School Records Request

The Alabama Department of Youth Services School District

PO Box 66

Mt. Meigs, Alabama 36057

Telephone: 334-215-3856

Fax: 334-215-3857

Records Request Form

Complete and mail to: Dr. Tracy Smitherman, PO Box 66, Mt. Meigs, AL 36057

I hereby authorize Alabama Department of Youth School District (DYS) to release all educational, medical,

social and/or psychological information that has been made a part of the school records regarding the student

listed below. I further release DYS from all liability and claims pertaining to disclosure of the information

requested.

STUDENT’S LEGAL NAME (when registered in DYS):

Last Name

First Name

Date of Birth

Date graduated or withdrawn from DYS

Contact Number

Last 4 digits of SSN

Records Requested by: _________________________________________ (Print Name)

_________________________________________ (Original Signature)

Relationship to Student: ____Self (if over 18) ____ Parent or legal guardian (

documentation must provide guardianship)

*Please note: A photo ID is required for all records requests.

Records Being Requested:

_____All Records

_____Official Transcript & Test Scores

_____Only the specific records listed:

(ie: Unofficial Transcript, Birth Certificate, Immunization Records, Trade certificate, etc.)

Records should be:

_____Held for pick up in DYS Central Office at 1000 Industrial School Road, Mt. Meigs, AL 36057

(*A photo ID must be presented to pick up student records)

Sent by US Mail* to: __________________________________________

(*Photo ID attached to this request)

3/2/16

School Records Request