Transcript Request - Platteville Public Schools

PERMISSION TO RELEASE RECORDS

Platteville High School, 710 E. Madison St., Platteville, WI 53818

I, the undersigned, hereby authorize and request Platteville Public schools to release copies of pupil records as indicated below for the following student:

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Student Name: (Please indicate name under which you graduated.)

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Year of Graduaton:

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Date of Birth:

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Records to be released:

	Official High School Transcript			ACT College Admission Test Results
	SAT College Test Results			Standardized Achievement Tests
	Health Records			Psychological Tests
	Personality Evaluations			Teacher Reports

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Send these records to the following address (include name of University, if appropriate):

I understand the need or pupose for such disclosure is: (employment, admissions, personal use, etc.)

I understand that this consent may be revoked by me at any time except to the extent that action has already been taken. This consent expires on (one year after the date of this request):

I understant that I have a right to inspect and receive a copy of the material to be disclosed and a copy of this consent form (Section 51/30(4) , Wis. Stats.) This consent (unless revoked earlier) expires upon:

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Signature of parent, legal guardian, or adult aged student:

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Date Requested:

To be sent with application or other documents: Yes No

Date Sent:

Confidentiality of these records is assured by the Family Education and Privacy Act of 1974 and by Wisconsin Statute 118.25.