CANTON CENTRAL SCHOOL DISTRICT 99 State Street Canton, NY 13617 PHONE: (315) 386-8561

FAX: (315) 386-1323 (District Office)

www.ccsdk12.org

REQUEST FOR STUDENT INFORMATION From: Canton Central School District – (High School Guidance Office) Fax: (315) 379-1239

To:

Date:

RE: Student: Grade:

Date of Birth:

Parental Consent for Release of Student Information: As parent or legal guardian of the above named student, I give permission for your school or agency to discuss and/or forward a copy of his/her records as requested.

Signature:

Date:

Relationship to student: Note: the above request for student information in compliance with Public Law 93-380 and Federal FERPA regulations.

Please send the following items for the above listed student: (check all that apply) o Immunization Record o Pertinent psychiatric and/or o School Health History medical history o Cumulative Records o Migrant /Education forms o Report Cards/Transcripts o Free and/or Reduced lunch and current schedule forms o Standardized and/or NYS Test o ______________________ History o ______________________ o Custodial documents o ______________________ o Withdrawal grades or grades to date o Special education documents

Office use only:

Date faxed:____________

Dated received:________________