Tipton Academy

REQUEST FOR RECORDS
 
STUDENT INFORMATION
 
Student Name: _____________________________________________________________
 
Address: __________________________City:_________________ St.____ Zip_________
 
Phone Number: _______________________________ Date of Birth: __________________ □ Male      □ Female
 
 
 
School Releasing Information
 
School Name: _______________________________________________________________
 
Address: _______________________ City: _____________________ St. ____ Zip________
 
School Phone Number: (____)_______________________ Fax: _______________________
 
 
Records Requested CA-60 with all records/grades, etc. including but not limited to IEP’s Immunization Records, etc.
 
SCHOOL TRANSFER WEAPONS FREE SCHOOL ZONE STATEMENT
 
The above student is currently enrolled at Tipton Academy. In order to comply with Public Act 328, please verify that he/she has not been suspended or expelled from school for a weapons violation subsequent to January 1, 1999. If the above has been suspended or expelled due to weapons violations, please attach an explanation as to the current status of the student.
 
 
Parent/Guardian Signature:___________________________________Date:_____________