STUDENT RECORD RELEASE

STUDENT RECORD RELEASE

To Releasing Counselor:

Date ______________

______________________________________________________________________
School Name

______________________________________________________________________
Address

CITY: _____________________________________________ STATE: ____ ZIP: ___________

Dear Counselor:

My children have been withdrawn from your school. Please release their academic and health records to the following school.

Thank you.

I-HERC Academy
746 5th Street
Sealy, TX 77474-2612

Students' Names, Age, and Grade Level at withdrawal time:

STUDENT'S NAMES	AGE	GRADE LEVEL AT WITHDRAWAL TIME

1. ________________________________________	____	_________________________________

2. ________________________________________	____	_________________________________

3. ________________________________________	____	_________________________________

4. ________________________________________	____	_________________________________

________________________________________ Signature of Requesting Parent		________________________________________ Signature of Receiving Principal