Records Request Form

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Jefferson City Public Schools Records Request Form

Due to construction, the JCHS Counseling office is not able to arrange for pick-up service at the high school. If you would like to request records from Jefferson City High School, JCAC, or Simonsen please fill out this form COMPLETELY. **All GED requests are handled by DESE at 573-751-3504.**

	3rd Party Education Verification requests must submit a signed release before records will be released. You may submit these requests by fax to: 573-659-3207 or email to: dulce.stevens@jcschools.us. 3rd Party requests submitted using this form will not be accepted.

	Please note: This form does not work in Internet Explorer

1.	Student's Name (at time of attendance)*

2.	Date of Birth:*

3.	Your Phone #:*

4.	Your E-mail address:

Records You Would Like Sent:*

Transcript

Health

ACT/SAT Scores

Good Student Drive Discount

IEP/Diagnostic Summary/504

Attendance

A+ Stamp (If student qualified for A+ while at JCHS)

Enrollment Letter

Other, please specify

6.	Year Graduated/Last Attended:*

7.	Are you transferring to a new high school?
	Are you transferring to a new high school? YesNo

Name, Address, Phone #, and Fax # for where records should be sent:
Enter at least 1 response.

1.
2.
3.

	Signature of Requesting Person (must be requesting person unless 17 years or under):

9.	I, the requestor, for this Records Request, warrant the truthfulness of the information provided in this application. Please type your First and Last Name *

10.	I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*
	I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.* YesNo