5125.1

FORM E

MENTOR PUBLIC SCHOOLS

PUPIL INFORMATION RELEASE FORM

(PLEASE PRINT)

 

Name___________________________________________  SS# ____ - ___ - _____

     Last               First            MI              (Maiden)

 

Address                                           

                                                                                                   

                                    Yr. of graduation or Yr. last attended

 

I hereby authorize the Mentor Public Schools to forward the following information:

 

                                                                         Circle YES or NO for each item

 

 1. Grades in courses                             YES     NO

 2. Attendance                                    YES     NO

 3. Achievement test data                         YES     NO

 4. Aptitude test data                            YES     NO

 5. Mental ability data                           YES     NO

 6. College entrance test data                    YES     NO

 7. Character reference                           YES     NO

 8. List of extracurricular activities            YES     NO

 9. Honors/Awards                                 YES     NO

10. Health records                                YES     NO

 

11. Other (please specify)                                         

 

I grant Mentor Public Schools permission to forward the above information for

legitimate reasons:

 

A. To colleges                                    YES     NO

B. To prospective employers                       YES     NO

 

C. Other (please specify)                                         

These records are to be forwarded to:

 

      Name                                                               

 

      Address                                                            

 

      City ______________________________  State ________  Zip           

 

EXPIRATION DATE:  Before a student reaches 18 years of age, this form must

 be signed by a parent.  When a student reaches 18 years of age, he must sign

 a new form, designating the information he wishes released.

 

___________________                                                                    

Date                     Signature of Parent/Guardian or

8/5/77                               Student 18 years of age

Revised 8/29/00