Home Student Records Request Form Student Records Request Form Requestor Information First Name Last Name Contact Information Phone Email Charter School Information Name of Closed Charter School Attendance Date Attendance Start Date Attendance Start Date: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Attendance Start Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Attendance End Date Attendance End Date: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Attendance End Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Did the Student Graduate? Yes No Records Being Requested Records Being Requested (Check all that apply) Attendance Records Exceptional Student Education Records Copy of Diploma Immunization Records Copy of Transcripts/Final Grades Standardized Test Results Cumulative Student Folder Withdrawal Form Disciplinary Records Enrollment Records Other: If other: Please add the records that you are requesting Student Information Student First Name Student Last Name Student Info Date of Birth Records Send Records To: Email Mail Pick up in-person Email records to Attention To Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code 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. Signature Sign above Relationship to Student (Check the applicable box): Self (if over 18) Parent/legal guardian* Other* *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 Submit Leave this field blank