Adult Education Transcript Release Form

The following student is applying for admission to the Virtual Learning Academy Charter School Adult Education Diploma Program. The Virtual Learning Academy Charter School is required to obtain written consent from the student before personally identifiable information from a student's education records is disclosed to any party other than those who are permitted access by law. Consent is also required before personally identifiable information is used for any other purpose than to aid in the planning for and provision of appropriate educational services to the student.

First Name

Last Name

Maiden Name (if applicable)

Street Address

City

State

Zip Code

Date of Birth

School #1 : Records to be disclosed by: (Name of School)

School #1 : Records to be disclosed by: (address of school)

City

State

Zip Code

Fax number

School #2 : Records to be disclosed by: (Name of School)

School #2 : Records to be disclosed by: (address of school)

City

State

Zip Code

Fax number

Please indicate your response to this request by checking the box, that reflects your decision, and then sign the document on the following page. A copy of the records to be released will be provided to you upon request. Thank you.

I CONSENT to the disclosure of the information as described above within one year of the date belowI DO NOT CONSENT to the disclosure of the information as described above

Hidden Fields

Contact Information