Release of Records Request

Release of Records Request

Name of Parent/Guardian (Student name if 18 years of age or older): 

Parent Phone Number: 

Address: 

City: 

State: 

Zip 

The name of school/agency/other you are authorizing to release records or portions of records for educational purposes to/from the Evansville Vanderburgh School Corporation (EVSC) (i.e. last school attended): 

Address of school/agency: 

School/agency phone number: 

School/agency fax number: 

School/agency email: 

Name of the student whose record is being requested: 

Student Date of Birth:     (If before 1980, list birthdate: 

School last attended or currently attending: 

I am authorizing the release of (Please check all that apply):

 Discussion and/or Exchange of Information

  Release of Records

This release includes (please check all that apply)

 Attendance

 Grades

 Discipline

 IEP/ISP/504

 Psychological Reports

 State Testing

The reason for this request is (i.e. enrollment, collaboratio of services, etc.): 

 

Entering your signature below authorizes the release of requested records. 

Parent/Guardian Signature: 

Date: 

These records may not be released to another party and/or agency without prior approval of the parent/guardian and/or eligible student, except when a written request is made by another educational institution outside the Evansville Vanderburgh School Corporation. 

This release may be revoked at any time upon written request of parent/guardian or student if 18 years or older. You have a right to a signed copy of this authorization. 

EFFECTIVE FOR ONE FULL YEAR.



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