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Parental Permission to Request or Release School Records for GCC 2021-22

I hereby authorize Greensburg Central Catholic Junior-Senior High to request and/or release records relative to my children's previous educational experiences.

First Parent/Guardian Name

First Name*

Last Name*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Second Parent/Guardian Name

First Name*

Last Name*
Second Parent/Guardian Date of Birth*
Third Parent/Guardian Name

First Name*

Last Name*
Third Parent/Guardian Date of Birth*
Fourth Parent/Guardian Name

First Name*

Last Name*
Fourth Parent/Guardian Date of Birth*
Fifth Parent/Guardian Name

First Name*

Last Name*
Fifth Parent/Guardian Date of Birth*
Sixth Parent/Guardian Name

First Name*

Last Name*
Sixth Parent/Guardian Date of Birth*
Seventh Parent/Guardian Name

First Name*

Last Name*
Seventh Parent/Guardian Date of Birth*
Eighth Parent/Guardian Name

First Name*

Last Name*
Eighth Parent/Guardian Date of Birth*
Ninth Parent/Guardian Name

First Name*

Last Name*
Ninth Parent/Guardian Date of Birth*
Tenth Parent/Guardian Name

First Name*

Last Name*
Tenth Parent/Guardian Date of Birth*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Name of Student

Full Name (First Middle Last) *
Student Date of Birth

Date of Birth *
Current School Attending

Current School *
Records Requested
Attendance Data
Report Cards (Past and Current)
Group Aptitude and Achievement Testing
Health, Medical and Dental Records
Personal History
Psychological Reports
Psychiatric Evaluations
Special Education Due Process Papers and IEP
Speech and Language Evaluations
Instructional Support Plans and Summaries
Others: (Specific reports, e.g., Occupational and Physical Therapists, Neurological Evaluations, etc. known by parents to be available) Please list below.

Others
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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