Records Release Consent Form – The Center for Lifelong Learning

Records Release FOrm

By filling out the form below you are allowing your student’s academic coach to have access to their school records. Coaches will only use this information for the purpose of aiding their lesson plans. Coaches will never share information or use it outside of its intended purpose.

Academics Records Release Permission

Phone

This field is for validation purposes and should be left unchanged.

Student Name(Required)

First Last

Student Birthdate(Required)

Parent/Guardian Name(Required)

Student's Current Grade

Parent Phone(Required)

Parent Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Records to be Released(Required)

Student’s Grades and Assignments

Hard Copy of ISP

Parent/Guardian Initials(Required)

By typing in your initials below, you are signing your agreement to release the records indicated in this form.