Genesee Valley Central School
1 Jaguar Drive
Belmont, New York 14813
Fax Number: 585-268-7990 Ph. 585-268-7900 ext. 1220
Authorization for release of former student information from Genesee Valley Central School to another school or a third party.
Name of Student (at time of enrollment): _________________________________
Date of Birth: ___________________ Phone Number: __________________
Graduate: Yes No
Year of Graduation or year of withdrawal: ________________________________
TYPE OF TRANSCRIPT
Official (will NOT be sent to individual)
ACT/SAT scores are listed on the transcript --- option only if scores were sent to Genesee Valley C.S. or the former Angelica or Belmont school.
Address of school, company, agency, or individual:
I hereby give permission to the Genesee Valley Central School District to release all records (name, address, birth date, grade level completed, grades, class rank, attendance record, test scores and CSE/evaluation records).
(Applicants Signature) (Date)