Consent to Release Form
Consent to release information
Name of Student *
Student Date of Birth *
Previous school attended *
Phone number of school *
Mailing address of school *
In accordance with the federal regulations regarding the privacy rights of parents and students Under the Family Educational and Privacy Act of 1974, the undersigned hereby consents to the release to Beacon Academy of all the educational records (including statement of disciplinary action or disciplinary records) and other information as may be requested about the above-named individual.
Type parent name (this will be considered your electronic signature) *
To the Principal or Secretary or Registrar: This student is applying for admission to Beacon Academy. We would appreciate your prompt sending of the following documents: *Transcript and latest grades *Standardized test results *Any special testing results or placement in special programs *Certificate of immunization and health records *All disciplinary records or official statement of disciplinary action Please Send All Information To: Beacon Academy PO Box 1235 Collegedale, TN 37315 Office (423)615-9753 Fax (706) 937-6851
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