OFFICIAL REQUEST FOR RECORDS

Today's Date * +

Please send records to:

Academy of Warren

Attn: Student Records

13943 E. 8 Mile Rd.

Warren, MI 48089

TEL: (586) 552-8010 FAX: (586) 552-4749

Student's Last Name *

Student's First Name *

Student's Date of Birth * +

Please submit the following information but not limited to:

Academic Records * Attendance Records * Transcript/Grades * Standardized Test Data * Discipline Records * Confidential Information (legal, psychological reports, social work reports) * Individualized Education Plan * Section 504 Plan * and other information pertaining to special services support * Medical Records

Michigan UIC# _____________________

Name of Previous School/Agency *

School Address, City, State, Zip Code *

Telephone *

Fax Number *

Parent/Guardian Electronic Signature (use your mouse or finger for trackpads and touchscreens) *

clear

The Family Educational Rights and Privacy Act (FERPA) permits the disclosure of personal identifiable information from a student's educational record without the consent of the parent/guardian or eligible student when the educational record is being sent to another school where the student seeks or intends to enroll if the disclosure is for the purposes related to the student's enrollment or transfer.

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