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_______________________