Brookville High School

Attn:  School Counseling Office

100 Laxton Road

Lynchburg, VA  24502

Phone:  434-239-2636

Fax:  434-239-6706

Authorization to Release Scholastic Records

Name:_________________________________________________________________________

            First                                     Middle                            Maiden                                    Last

Date of Birth:____________________ Daytime Phone Number___________________________

Year of Graduation/year you left or dropped school____________________________________

Type of Information Being Requested (Please check the appropriate line)

___Official Sealed Transcript for College

___Unofficial transcript for personal use

___Verification of Graduation for employment

___DMV ID:  b.)___Immunization Record  c.) ___Other(describe)________________________

___Number of copies needed

__Pick Up/Call when Ready:_________________________

__Send to Address Below:

Name:_____________________________________________________________________________

Organization:_______________________________________________________________________

Street Address: _____________________________________________________________________

City: ______________________________, State _______________  Zip_____________

Please allow 3 – 5 business days for processing your request.

There is a $3.00 Fee for this request in the form of cash, money order or good check.

I authorize Campbell County Schools/Brookville High School to release the information from my scholastic record as indicated above.

SIGNATURE:

 Date Transcript Mailed/Faxed/Given_______________________