 |
Southeast
Academy
137
Palmer Ave
Saltville,
VA 24370
276-496-7791
ext. 21
276-496-7979
Fax
Consent
for Release of Student Records |
To
be filled out by the parent and mailed/delivered to the past
school.
Date:
_________________________
I
Hereby give my consent to
______________________________________________________ at
(School,
Agency, or Person)
________________________________________________
to release the information listed below
(Address)
regarding
_______________________________________________,
birth date _______________,
(Student’s
Name)
grade_________
to:
Southeast
Academy.
Attention: Admissions
Director
Address:
P.O.
Box MM, 137 Palmer Avenue, Saltville VA 24370
Please
include:
-
Up-to-date transcript (including dates of entry/withdrawal, grading scale, all subjects, and grade to date of withdrawal), SOL and/or standardized test results;
-
Any psychological or special placement date (SLD, EMR, etc.);
-
Health records (including physicals and immunization record).
The
Federal
Register, Volume 41, No. 118, Section 99.31,
June 17, 1976, states:
PRIOR
CONSENT FOR DISCLOSURE NOT REQUIRED IF THE DISCLOSURE IS TO
OFFICIALS
OF ANOTHER SYSTEM IN WHICH THE STUDENT SEEKS ADMISSION OR INTENDS
TO ENROLL.
_______________________________________________________________________
Signature of Parent/Guardian
Date
| School Instructions: |
Please mail records to: |
Southeast Academy
137 Palmer Ave
P.O. Box MM
Saltville, VA 24370 |
|
|
