Consent to Release Form
Consent to release information
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Name of Student *
Student Date of Birth *
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DD
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YYYY
Previous school attended *
Phone number of school *
Mailing address of school *
In accordance with the federal regulations regarding the privacy rights of parents and students Under the Family Educational and Privacy Act of 1974, the undersigned hereby consents to the release to Beacon Academy of all the educational records (including statement of disciplinary action or disciplinary records) and other information as may be requested about the above-named individual.
Type parent name (this will be considered your electronic signature) *
To the Principal or Secretary or Registrar:                                        This student is applying for admission to Beacon Academy. We would appreciate your prompt sending of the following documents:                                                                                             *Transcript and latest grades                                                              *Standardized test results                                                               *Any special testing results or placement in special programs       *Certificate of immunization and health records                              *All disciplinary records or official statement of disciplinary action                                                                                                       Please Send All Information To:                                                      Beacon Academy                                                                                 PO Box 1235                                                                               Collegedale, TN  37315                                                                  Office (423)615-9753     Fax (706) 937-6851 treasurer@beaconacademy.us
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