Records Request Form

	3rd Party Education Verification requests must submit a signed release before records will be released. You may submit these requests 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:*

5.	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

8.	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