22-23 Records Request Form
Request Student Records
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Date of Request *
MM
/
DD
/
YYYY
Type of Records Requested *
Required
Additional Comments on Records Requested
STUDENT First Name *
STUDENT Last Name *
STUDENT Status *
REQUESTER Full Name (if other than student)
Requester Phone Number
Requester Email Address *
Is This Records Request for a Current Student Withdrawal? *
If The Answer to This Question is YES, Please be Sure to Complete a STUDENT WITHDRAWAL FORM
Method of Delivery *
Mail/Fax/Email Records to:
IF YOU ARE AN EDUCATIONAL OR HUMAN SERVICES AGENCY, PLEASE EMAIL ANY AUTHORIZATIONS TO  admissions@imhotepcharter.org
Date Records Due *
MM
/
DD
/
YYYY
Submit
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