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Student Records Release Authorization Form
For parents/guardians of students entering the Pittsfield Public Schools district from another school district.
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* Indicates required question
Email
*
Your email
Date:
*
MM
/
DD
/
YYYY
Student Name
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
I authorize the release of academic, disciplinary, special education, health and personal records regarding the above-named student(s) from the following:
(Fill out previous school and doctor information below)
Previous School Name:
Your answer
Previous School City:
Your answer
Previous School State:
Your answer
Parent Name/Signature - Please sign below by typing your name. This confirms that you authorize the offices listed above to release the student's records to Pittsfield Public Schools for the purposes of registering your child in the district.
Parent/Guardian Name:
*
Your answer
Relationship to student:
*
Your answer
Please return to
http://www.pittsfield.net/cms/One.aspx?portalId=1051934&pageId=1221327
to complete other required forms - PPS Registration Form and Home Language Survey (required for all students)
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