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Previous School Records Request Form

PEACE ACADEMY

To Whom It May Concern

School Name

District

Phone

Fax

Email

Address

In accordance with the Family Education Rights and Privacy Act (FERPA), 34DFR 99.31, transfer of education records is requested for:

Student Name

Date of Birth

Grade

Student Name

Date of Birth

Grade

Student Name

Date of Birth

Grade

Student Name

Date of Birth

Grade

Please Include the Following (Checklist)

Birth Certificate

Copy of SS Card or ID Number

Report Cards, Standardized Test Scores, Attendance Records

Any Special Education Information Records

Health & Immunization Records

Any Special Need Accommodations

Disciplinary Referrals, Counseling, Detention and/or Suspension Records

Parent / Guardian Name

Date

Parent / Guardian Signature

We request that all permanent school records of the student(s) be mailed, emailed or faxed to:

PEACE ACADEMY

4620 S. Irvington Ave.

Tulsa, OK 74135

Phone: 918.627.1040

Fax: 918.561.6875

Email: office@patulsa.org

OFFICE USE ONLY

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