Name of Applicant *

First Name

Last Name

Release Statement

I give permission to the authorities in the above mentioned school to release a copy of the records for my child to Chesterton Academy of St. Michael.

Official administrative records (grade completed, attendance records).

Report cards for the last two years including teachers comments.

All standardized test scores.

All disciplinary records.

Any record of special honors, prizes, special achievements and volunteer activities.

Name of Parent *

First Name

Last Name

Date of Request by Parent *

MM

DD

YYYY