COMPTON UNIFIED SCHOOL DISTRICT
Pupil Records Department
Authorization to Release Student Records
This form was created in accordance with Senate Bill (SB) 1845 and Public Law (PL) 93-330, and CUSD Board Policy (BP) 5125.
Date:
Student Information
First Name: |
Last Name: |
Middle Name: |
Maiden Name: |
CUSD ID or State ID#: |
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If you have changed your name since attending a CUSD school, other than through marriage, please send a copy of the legal document(s) showing both your former name and new name. Your request will not be processed without this required documentation. A legal document may be a copy of Naturalization Certificate (copy of both sides) or Court document indicating the name change.
Home Phone #:( |
) |
- |
Cell Phone#:( |
) |
- |
Email: |
@ |
I authorize and request the Compton Unified School District (CUSD) to release school information, including school records pertaining to my courses, grades, attendance, and any psychiatric, social, or scholastic evaluations, including special education evaluations and testing regarding the student named above to:
Name: _____________________________________________________________________
Address: ___________________________________________________________________
City: _____________________________ State: ______________________ Zip Code: ________________
Student Signature: _______________________________________ Date Signed: ____________________
I confirm that I am the student whose transcript is requested by this form. This signature authorizes the release of records.
NOTE:
Please include a copy of valid photo identification of the requesting student. The only forms of acceptable identification by the Compton Unified School District, Pupil Records Department are, any State Department of Motor Vehicle Identification Card or Drivers’ License, or Passport. Request will not be process without a proper identification submitted.
Pupil Records Department
603 S. Acacia Avenue, Compton, CA 90220
Phone: (310) 639-4321 Ext. 55133 or 55134 • Fax: (310) 604-0821
