Student Records Request Form

Student Records Request Form

Enter the student and previous school details, then complete the parent signature and printed name. Please complete this form for each school from whom we will be requesting records.
Student's Full Name

First NameLast Name
Student's Date of Birth

MonthDayYear
Date
Student's Grade
Previous School Name
Previous School Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous School Fax Number
Previous School Email
example@example.com
Is there another student from this school for whom we need to request records?
Student 2 Full Name

First NameLast Name
Student 2 Date of Birth

MonthDayYear
Date
Student 2 Grade
Is there another student from this school for whom we need to request records?
Student 3 Full Name

First NameLast Name
Student 3 Date of Birth

MonthDayYear
Date
Student 3 Grade
Is there another student from this school for whom we need to request records?
Student 4 Full Name

First NameLast Name
Student 4 Date of Birth

MonthDayYear
Date
Student 4 Grade
Parent/Guardian Printed Name

First NameLast Name
Parent/Guardian Signature
In order to provide proper placement and quality educational services, we request that you send us the following records:
- Check-out Grades
- Disciplinary Records
- I.E.P. and Special Education Records
- Immunization Records
- Information on Special Circumstances (Custody, Court Orders, Etc.)
- Most Recent Class Schedule/Placement
- Testing Information
- Transcript/Attendance Records
Public Law 93-380, regarding the "Release of School Records" has been modified by SB 182, Article 5, Privacy of Pupil Records, 10947 which reads: "A school district is not authorized to permit access to pupil records to any person with parental consent or under judicial order except that: Access shall be permitted to the following: "Officials and employees of other public school systems including local, county, or state correctional facilities where educational programs leading to high school graduation is provided. Where the pupil intends to or is directed to enroll, subject to the right of parents is provided in Section 1039"

** Permission to release these records to Park County School District # 16 is granted through federal law 34CFR 300.71 and FERPA (Family Educational Rights and Privacy Act) section 99.1; the Wyoming Educational Code 3 21-13-315 and the "1992 Wyoming Department of Education Rules and Regulations Governing Services for Children and Disabilities" section 23(a). You need only to send parents notification that the records have been sent.

Please fax to 307-868-9264 or email to abolli@park16.org

Meeteetse School - PCSD #16

PO BOX 218

Meeteetse, WY 82433

307-868-2501

307-868-9264 (Fax)
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