302 Second St, SW
Roanoke, VA 24011-1502
540-345-1688
AUTHORIZATION
FOR RELEASE/EXCHANGE OF
RECORD INFORMATION
STUDENT’S NAME __________________________________________________
ADDRESS
____________________________________________________________
DATE OF
BIRTH________________________________________________________
CURRENT OR LAST GRADE COMPLETED _______________________________
FOR
STUDENTS ENROLLING IN COMMUNITY HIGH SCHOOL
I
hereby request that (SCHOOL)
______________________________________ release a transcript of all grades, credits, test scores and complete
health record to date of withdrawal for the student named above. Please send
this information to Community High School at the address listed above.
____________________________________
__________________________________
DATE OF
REQUEST
PARENT’S/GUARDIAN’S
SIGNATURE