Page 1 of 1

Seascape Academies
Authorization for Release of Student Records

Student Information

Full Name

Date of Birth

Grade Level (if known

Current / Previous School Information

School Name

School Address

City, State, Zip

Phone Number

Fax or Email

Please release the following student records to Seascape Academies:

Academic Transcript / Report Cards

Academic Transcript / Report Cards

IEP / 504 Plan

IEP / 504 Plan

Attendance Records

Attendance Records

Health / Immunization Records

Health / Immunization Records

Discipline Records

Discipline Records

Psychological / Speech / OT / PT Evaluations

Psychological / Speech / OT / PT Evaluations

Other: ______________________________________

Other: ______________________________________

Receiving School Information:

Seascape Academies [Your Address or “On File”] Savannah, GA Phone: (912) 604-2094 Email: angela.whitcomb@seascapeacademies.com

Authorization

I authorize the release of the records listed above to Seascape Academies for the purpose of enrollment and educational planning.

Parent/Guardian Name (printed):

Signature

Signature

Date

Relationship to Student

Relationship to Student
☐ I authorize communication between Seascape Academies and the current/previous school for clarification or additional information as needed.