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Records Request Permission Form
I authorize The Virginia School for the Deaf and the Blind to release a copy of my high school records as designated below:
* Indicates required question
Email
*
Your email
I authorize The Virginia School for the Deaf and the Blind to release a copy of my high school records as designated below:
*
High School Transcript
Special Education Records
Test Scores
Immunizations
Other:
Required
Name while attending High School :
*
Your answer
Current Name: Last/First/Middle
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
What department did you attend classes in?
*
Deaf
Blind
Other:
School Attended
*
Staunton Campus
Hampton Campus
Last Year Attended VSDB:
*
Your answer
Year Graduated:
*
enter NA if you attended but did not graduate
Your answer
I request
*
Records be picked up at VSDB
Copy be mailed or faxed directly to me
Copies be emailed to me
Official copy be mailed to a college
Unofficial copy be mailed or faxed to a business
Other:
Personal Address (Current):
*
Your answer
Phone:
*
Your answer
Personal Email Address:
*
Your answer
College or Business/ address/email/phone:
*
type NA if not sending to a college or business
Your answer
Signature:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
Submit
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