RECORDS REQUEST FORM

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THIS FORM MUST BE COMPLETED BY THE FORMER STUDENT ONLY. RECORD REQUESTS ARE PROCESSED AS QUICKLY AS POSSIBLE. DUE TO THE LOCATION OF FILES, IT MAY TAKE UP TO TWO WEEKS FOR US TO PROCESS. PLEASE PLAN ACCORDINGLY.

Email *

RECORD NEEDED (PLEASE CHECK) *

TRANSCRIPT

IMMUNIZATON RECORD

OTHER

Required

Name at time of Graduation (Maiden Name,etc.) *

Year of Graduation/Year left School: *

Date of Birth: *

YYYY

Daytime Phone Number: *

I Authorize Averill Park High School to send my records to:

Please choose ONE of the following forms of delivery. Please include all information needed to be able to send

I authorize Averill Park High School to MAIL my records to:

I authorize Averill Park High School to EMAIL my records to the following institution at the following email address:

I authorize Averill Park High School to Fax my records to the following institution at Fax number:

I would like to make arrangements to pick up my transcript.

Option 1- I will pick up my transcript in person.

By completing and submitting this form, you are confirming that you are the above-named person and you are agreeing to the terms and conditions allowing APCSD to release your records to the institution indicated on the form. *

By checking this box, I agree that I am electronically signing this form

Required

A copy of your responses will be emailed to the address you provided.

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