DATE: _______________________________

________________________________________________,
STUDENT'S NAME

a former student at your school, has begun enrollment proceedings at
_____________________________________________ School. A formal request seeking this student's records will follow. In the meantime, please review this student's records briefly and complete the form below. Reply by FAX [(xxx) xxx-xxxx], e-mail [xxxxxxxx@xxxx] or telephone [(xxx) xxx-xxxx ; ask for _________________] as soon as possible. Thanks.

DATE STUDENT LAST ATTENDED YOUR SCHOOL: ___________________________

LAST GRADE COMPLETED (IF ELEM/MIDDLE) OR # OF CREDITS EARNED _______

IS THIS STUDENT CURRENTLY UNDER SUSPENSION/EXPULSION? __ YES __ NO*
If yes, please give dates suspension/expulsion (circle one) was imposed and will expire:

_________________________________________
DATE STUDENT SUSPENDED/EXPELLED

_________________________________________
DATE SUSPENSION/EXPULSION WAS/WILL BE OVER

REASON FOR SUSPENSION/EXPULSION: __________________________________

*If "no," is reason that student dropped/transferred prior to board action? __ Yes __ No

RELATIONSHIP OF PERSON WITH WHOM STUDENT LIVED (CIRCLE ONE:)
parent/guardian

other family member

non-family member

alone

Is this student on the Sex Offender Registry?

_____ Yes (Please include documents with student records.)

_____ No

Was this student under an IEP? Did s/he have a 504 plan? A health plan?

____ Yes (If yes, please circle "IEP," "504 Plan,' or "Health Plan" above.)

____ No

If yes, please fax or send a copy of the most recent IEP, 504 plan, or health plan with this form.

Thank you, again!

NOTE: One school district may release a student's records without parental consent to "officials of another school [or] school system . . . where the student seeks or intends to enroll" provided the sending school has a policy that "includes a notice that the [school] forwards educational records to other [schools] that have requested the records and in which the student seeks or intends to enroll" or provided the parent or eligible student is the person who initiated the request to forward the records. 34 CFR §§ 99.31 and 99.34 (federal regulations implementing the Family Educational Rights and Privacy Act, 20 USC § 1232g, the Student Records law).

THIS FORM IS A SERVICE OF SCHOOL ADMINISTRATORS OF IOWA.