[Town of West Springfield] Student Record Release Form

Section 1 of 1 in this document

STUDENT RECORD RELEASE FORM

WEST SPRINGFIELD HIGH SCHOOL

Maiden Name

My Personal Email

Year of Graduation

CONSENT FOR DISSEMINATION OF STUDENT RECORD

Business or Institution Name 1

Business or Institution Email 1

Applying on The Common App?

Yes

I Don't Know

Business or Institution Name 2

Business or Institution Email 2

Applying on The Common App?

Yes

I Don't Know

Parts of Record to be Released

*Transcript

MCAS Results

Signature of Student or Parent

First Name

Last Name

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*The transcript shall contain administrative records that constitute the minimum data necessary to reflect the student's educational progress and to operate the educational system. These data shall be limited to the name, address, and phone number of the student; his/her birth date; name, address, and phone number of parent or guarfian; course titles, grades (or the equivalent when grades are not applicable), course credit, grade level completed, and the year completed. Commonwealth of Mass. Dept. of Education Regulation 23.02 (6) **This form may be signed by a student or former student of fourteen years of age or older, OR a student in the ninth grade or above, or a parent.

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Student Name

My Address

Date of Birth

CONSENT FOR DISSEMINATION OF STUDENT RECORD

Applying on The Common App?

Business or Institution Address 1

Applying on The Common App?

Business or Institution Address 2

Parts of Record to be Released

Signature of Student or Parent