Authorization for Record Release

AUGUSTA SCHOOL DISTRICT

Authorization for Record Release
Previous School/Agency*
Previous School Phone Number*
Previous school phone number.
Previous School Email*
Previous school email
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Grade*
Date Enrolled From

MonthDayYear
Date
Date Enrolled To

MonthDayYear
Date
Pursuant to Wisconsin Statutes 118.125(4) and Federal Regulations, Section 99.31/34, authorization is given to forward the above student's records by this official notification of student enrollment. An educational agency or institution may disclose personally identifiable information from an education record of a student without consent required by Statute 99.30 if the disclosure is to other school officials, including teachers, within the agency or institution whom the agency or institution has determined to have legitimate educational interests. Also, in accordance with the Family Educational Rights and Privacy Act of 1974 and Board of Education Policy 8330, this authorizes the exchange/release of information as requested.
Information to be disclosed to:

Augusta School District

E19320 Bartig Rd

Augusta, WI 54722

Phone: 715-286-2291

Email: enroll@augusta.k12.wi.us
Information to be disclosed:*

Complete transcript of course title/descriptions (including grades at time of withdrawal)Special Education Information (IEP, evaluation team reports, speech/language information)Attendance record of studentWIAA physical examination records (if applicable)Results of standardized tests and mandated state testsBirth verification recordsImmunization and health recordsOther
Parent or Legally Authorized Representative:
Parent/Guardian/Student over 18*

First NameLast Name
Relationship to Student*
Signature of Parent / Guardian*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

AUGUSTA SCHOOL DISTRICT