Name of Student Grade

NORTH KANSAS CITY SCHOOL DISTRICT

STUDENT RECORD RELEASE FORM

Name of Student Grade

Date of Birth Graduation Year

Previous School

Previous School Street Address
Previous School City, State, Zip
Previous School Phone number
Information to release (please check)
Permanent Record (Transcript)

Immunization Record

IEP and Diagnostic Summary

Discipline Report

___________ Test Scores (MAP, PLAN, ACT/ SAT, EOC or End of Course Exams)

___________ Copy of Birth Certificate

___________ A+ Attendance and tutoring

___________ Withdrawal Grade Percentages

Other (please specify)


Mail to: Oak Park High School

Counseling Center

825 NE 79^th Terrace

Kansas City, MO. 64118

Phone [phone]

Fax to: 816-413-5450

Authorization Statement and Signature

I authorize the above named former school to release the information checked to Oak Park High School.

Date Signature of Parent, Guardian, or Student over 18

Federal Law 99.21 states, “No parent signature required for education records sent to another educational agency.”