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1/31/2014

GREENVILLE AREA SCHOOL DISTRICT
AUTHORIZATION TO RELEASE PERMANENT SCHOOL RECORD FORM

Please submit completed form to Guidance Office - ATTN: Tabitha Gehly - 9 Donation Road - Greenville, PA 16125

The Guidance Office of the Greenville Senior High School is authorized to release the permanent record of _____________________________ to the institution(s) listed below. I understand this record will include official administrative record (name, address, birth date, grade level completed, grades, class standing and attendance record), standardized test scores, extracurricular activities and counselor recommendations (if other, please specify: ____________________________________ ).

Do you want your PSSA Test Results forwarded if available? _____ Yes _____No

Last year attending Greenville High School: ___________

Address: _________________________

_________________________

Phone: _______________________

E-mail: _______________________

Other: _______________________

______________________________
Signature of parent/guardian
(if student is under 18)

Receiving Institutions:

______________________________