SGS - Records Request Form - Permission 2023
SGS - Records Request Form - Permission 2023
By my (our) signature below, I (we), as parent(s) or legal guardian of the student(s) listed below give permission to the school listed below to release the school records to St. Gabriel School. Please send the records to: St. Gabriel School 9935 Johnnycake Ridge Rd Concord, OH 44060 to release the school records of
Student # 1 Name
Student # 1 Name
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First
Last
Date of Birth - Student # 1
Date of Birth - Student # 1
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Name of School to obtain Records
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Student # 2 Name
Student # 2 Name
First
Last
Date of Birth - Student # 2
Date of Birth - Student # 2
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Name of School to obtain Records
Student # 3 Name
Student # 3 Name
First
Last
Date of Birth - Student # 3
Date of Birth - Student # 3
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Name of School to obtain Records
Student # 4 Name
Student # 4 Name
First
Last
Date of Birth - Student # 4
Date of Birth - Student # 4
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Name of School to obtain Records
PLACE A CHECK BEFORE THE RECORDS AUTHORIZED TO BE RELEASED:
PLACE A CHECK BEFORE THE RECORDS AUTHORIZED TO BE RELEASED:
Grades and Academic Records
Psychologist Assessments and Records
Disciplinary Records
Attendance Reports
Medical Reports (Immunization Records/Screenings)
Testing Results and/or Evaluations (MAP Reports/IOWA)
Other, please specify:
Other, please specify:
Information obtained will be used in a confidential and professional manner. Please send records to:
St. Gabriel School
9935 Johnnycake Ridge Road
Mentor, Ohio 44060
ATTN: Student Records
Phone: 440.352.6169
Fax: 440.639.0143
Email: Michelle.Clarke@st-gabrielschool.org
Draw your signature into the box below. (Parent/Legal Guardian)
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Today's Date
Today's Date
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