Schools Records Request Form printable pdf download

Schools Records Request Form

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:

ulie.pearson@jcschools.us

OFFICE U SE O NLY

Date S ent:________________ B y:_________ M ail:_______ F ax:_______ E mail:_______ P ick U p:_______

Schools Records Request Form