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RECORDS REQUEST (Click here to print)
Parent: Submit the completed top portion with the application to Eastside Christian School
Submit the completed bottom portion to the applicant’s current/former school
The parent is to submit the “Request for Records” form to the current school.
This release gives Eastside Christian School permission to request and receive pertinent information
regarding the applicant from his/her former school, teacher, doctor, health clinic, hospital, or any additional
agency. All information received is considered confidential. This form will be maintained in the applicant’s file.
Applicant’s Full Name: ________________________________________________________________________________________
Last First Middle
Current Grade Level: ____________________ Date of Birth: _____/_____/_____
I authorize Eastside Christian School to obtain information from the administration, admission, guidance,
teachers and/or doctors or other professionals of the following schools/organizations for the purpose of
educational planning. I release all liability and all claims pertaining to the disclosure of this information:
Last school attended: Other School/Doctor’s office other: for release of educational records:
(Name) _________________________ (Name) _________________________
(Address) ________________________ (Address) _______________________
(Phone) _________________________ (Phone) __________________________
(FAX) ___________________________ (FAX) ___________________________
I hereby authorize and request the release of ALL medical, educational, disciplinary, social, and/or
psychological information regarding this applicant. All information will become the confidential property
of Eastside Christian School and is not subject to applicant or parental review.
_____________________________________ _________________________
Signature of Parent/Guardian Date
Should the student be accepted, discovered non-disclosure of information related to previous behavior
disorders, educational, emotional, or substance abuse history would be grounds for immediate dismissal
from Eastside Christian School.
Eastside Christian School does not discriminate on the basis of race, color, or national origin in the
administration of educational policies, admission policies, or employment practices.
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Parent: Deliver this portion of the form to the applicant’s current/former school
AUTHORIZATION AND PERMISSION TO RELEASE INFORMATION
Applicant’s Full Name: ________________________________________________________________________________________
Last First Middle
Current Grade: __________ Date of Birth: _____/_____/_____
Current/Former School/Organization Name: __________________________________
Address: __________________________________
Phone: __________________________________
FAX: _________________________________
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