Chaya Mushka Chabad Academy Release of Records Student Information Student's Full Name First Name Last Name Student Date of Birth MM DD YYYY School Information Name of Last School Attended Address of Current School Attended Address 1 Address 2 City State/Province Zip/Postal Code Country School Phone Number (###) ### #### Dates Attended School Grade level at time of withdrawal Consent Information I consent to the release of those records as indicated below: • Birth Certificate • Transcript of academic records • Standardized test results / Progress Monitoring • Health/Immunization records • Discipline records • Withdrawal papers, including grades, absences, and withdrawal date • Copy of grading scale • Special Education records • Guidance records I consent Your Name * First Name Last Name Today's Date * MM DD YYYY Thank you! We will reach out to the school with the information provided. Please let them know that a request for records is forthcoming.
