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    TRANSCRIPT/RECORDS RELEASE/REQUEST

    AUTHORIZATION FOR

    FORMER STUDENTS

    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)

    • Unofficial

     

    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)