JEFFERSON
C ITY
P UBLIC
S CHOOLS
R ECORDS
R EQUEST
F ORM
If
y ou
w ould
l ike
t o
r equest
r ecords
f rom
J efferson
C ity
H igh
S chool,
J CAC,
o r
S imonsen
please
f ill
o ut
t his
f orm
C OMPLETELY
a nd
a llow
7
b usiness
d ays
t o
p rocess
y our
r equest.
**All
G ED
r equests
a re
h andled
b y
D ESE
a t
5 73-‐751-‐3504.**
Student’s
N ame
( maiden
n ame):_________________________________________________________________
Date
o f
B irth:
_ _________________________
Your
P hone
# :_____________________________________
Circle
R ecords
Y ou
W ould
L ike
S ent:
Transcript
Good
S tudent
D river
D iscount
Health
IEP/Diagnostic
S ummary/504
ACT/SAT
S cores
Attendance
Year
G raduated/Last
A ttended:
_ ________________Transferring
t o
n ew
h igh
s chool?
_ __________
Name,
A ddress,
P hone
# ,
a nd
F ax
#
f or
w here
r ecords
s hould
b e
s ent:
1._____________________________________________________________________________________________________
2._____________________________________________________________________________________________________
3._____________________________________________________________________________________________________
Signature
o f
R equesting
P erson
( must
b e
r equesting
p erson
u nless
1 7
y ears
o r
u nder):
____________________________________________________________________________
Date
o f
R equest:
_ ____________________________________
Jefferson
C ity
H igh
S chool
–
6 09
U nion
S treet,
J efferson
C ity,
M O
6 5101
Phone
5 73-‐659-‐3070/Fax
5 73-‐659-‐3207
Email:
j
ulie.pearson@jcschools.us
OFFICE
U SE
O NLY
Date
S ent:________________
B y:_________
M ail:_______
F ax:_______
E mail:_______
P ick
U p:_______