JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Authorization for Release of Records
This is an official request for a student's education records. The information contained in this request should be considered private. Please complete all information in full and then finalize your request by clicking 'SUBMIT'.
PLEASE NOTE: Education verifications do not require a signed release. In accordance with the Family Educational Rights and Privacy Act of 1974 and California State Law; CORE Butte Charter School will release and MAIL to the school named below the student records requested via this form.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Requestor's Name
*
Your first and last name
Your answer
Place of Employment
*
Your answer
Phone Number
*
What is the best number to reach you at if we have questions?
Your answer
Reason for request
*
New School of Attendance (TK-12)
Other:
Student Name
*
Your answer
Name while attending CORE (if different)
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Grade
*
Your answer
Student's First Date of Enrollment at Requestor's School
*
What date did the student start attending, or what date do you anticipate the student to attend your school?
MM
/
DD
/
YYYY
Please release and mail the following records:
*
Special education records include IEPs, ITPs, BIPs, academic assessments, speech & language assessments, psychological evaluations, and any other pertinent special education related information.
Cumulative Record
Health Records
Special Education records
Transcript of Completed Work to Date
Other:
Required
Please Fax the following URGENT document ASAP
Your answer
Fax #
Your answer
Please mail documents to: School Name
*
Your answer
Please mail documents to: School Address
*
Your answer
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This form was created inside of CORE Butte Charter.
Does this form look suspicious?
Report
Forms
