Student Records Request Form

Requestor Information
Contact Information

Charter School Information
Attendance Date
Did the Student Graduate?

Records Being Requested
Records Being Requested (Check all that apply)

Student Information
Student Info

Records
Send Records To:
Address

Signature

I hereby Authorize the Arizona State Board for Charter Schools (ASBCS) to release all educational, medica, social and/or psychological information that has been made a part of this schools records request regarding the student listed above, I further release ASBCS from all liability and claims pertaining to disclosure of the information requested.

Sign above
Relationship to Student (Check the applicable box):
*Please note if records requested are for a prior student 18 years or older, the student must sign this form or signed release from must be a provided in order for ASBCS to release the information