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23-24 Records Request Form
Request Student Records
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* Indicates required question
Date of Request
*
MM
/
DD
/
YYYY
Type of Records Requested
*
Unofficial Trascript
Official Transcript
Duplicate Diploma/$10 FEE
Enrollment Verification Letter
Copy of Medical Records
Copy of Enrollment Documents
Report Card
Attendance Report
Other:
Required
Additional Comments on Records Requested
Your answer
STUDENT First Name
*
Your answer
STUDENT Last Name
*
Your answer
STUDENT Status
*
Choose
Current Student
Graduate
Former Student (Non-Graduate)
REQUESTER Full Name (if other than student)
Your answer
Requester Phone Number
Your answer
Requester Email Address
*
Your answer
Is This Records Request for a Current Student Withdrawal?
*
If The Answer to This Question is YES, Please be Sure to Complete a STUDENT WITHDRAWAL FORM
No
Yes
Method of Delivery
*
Email
Faxed
Picked Up
Mailed
Mail/Fax/Email Records to:
IF YOU ARE AN EDUCATIONAL OR HUMAN SERVICES AGENCY, PLEASE EMAIL ANY AUTHORIZATIONS TO
admissions@imhotepcharter.org
Your answer
Date Records Due
*
MM
/
DD
/
YYYY
Submit
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