request for student permanent records


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Cornerstone Christian Academy PO Box 1608 Bloomington, IL 61702-1608 (309) 662-9900

REQUEST FOR STUDENT PERMANENT RECORDS Date: _____________________ ______________________________________________________________________ School Most Recently Attended ______________________________________________________________________ Mailing Address _______________________________________________________________________ City State Zip

Please release the following information for: _____________________________________________________________________________ Student Name

Birthdate

Grade

Academic Records Behavioral Records Standardized Test Data Psychological and Other Testing Medical/Health Records Transfer Record from Other School Individualized Education Plan and/or 504 Plan (if applicable) Records may be sent to: Cornerstone Christian Academy Attn: Admissions P.O. Box 1608 Bloomington, IL 61702 Fax: (309) 662-9904 [email protected] Parent Signature:_________________________________________________________________ **In accordance with revised federal and state statutes, permission of the parent or adult student is no longer required when records are requested by authorized school personnel.