Release of Records Request Form

By completing the information below, you are giving the EVSC approval to request records from another school corporation or entity. This form is for students new to the EVSC only, or as requested by our school. If you are moving to another district from the EVSC, you do not need to complete this form.

Release of Records Request

Name of Parent/Guardian (Student name if 18 years of age or older):

Parent Phone Number:

Address:

City:

State:

Zip

The name of school/agency/other you are authorizing to release records or portions of records for educational purposes to/from the Evansville Vanderburgh School Corporation (EVSC) (i.e. last school attended):

Address of school/agency:

School/agency phone number:

School/agency fax number:

School/agency email:

Name of the student whose record is being requested:

Student Date of Birth: (If before 1980, list birthdate:

School last attended or currently attending:

I am authorizing the release of (Please check all that apply):

Discussion and/or Exchange of Information

Release of Records

This release includes (please check all that apply)

Attendance

Grades

Discipline

IEP/ISP/504

Psychological Reports

State Testing

The reason for this request is (i.e. enrollment, collaboratio of services, etc.):

Entering your signature below authorizes the release of requested records.

Parent/Guardian Signature:

Date:

These records may not be released to another party and/or agency without prior approval of the parent/guardian and/or eligible student, except when a written request is made by another educational institution outside the Evansville Vanderburgh School Corporation.

This release may be revoked at any time upon written request of parent/guardian or student if 18 years or older. You have a right to a signed copy of this authorization.

EFFECTIVE FOR ONE FULL YEAR.

Elementary

Middle

High

District Wide

Release of Records Request Form