MARIEMONT CITY SCHOOLS

6743 CHESTNUT STREET

CINCINNATI, OH 45227

PERMISSION TO RELEASE SCHOOL RECORDS

1. I give permission to the Mariemont City School District to place SAT Reasoning Test scores, SAT Subject Test scores, ACT scores, and AP scores on the high school transcript Yes, I give permission ____ No, I do not give permission _____

2. I give permission to the Mariemont City School District to release the following school records upon request (please check those to be released):

_____high school courses, grades, credits, GPA, class rank (transcript)

_____ACT scores, SAT Reasoning Test scores, SAT Subject Test scores

_____AP scores

_____other, such as special education documents, health records, birth certificate, custody information, etc. (please list: _______________________)

3. I request that the above records be released:

_____ to all schools, persons, or agencies that I request verbally or in writing during high school years and years following graduation

_____ only to this specific college, university, agency, or person one time :

___________________________

Name of student __________________________________________

Birthdate: __________________________

Social Security Number: ____________________________________

________________________________________ ________________

Signature of parent, legal guardian, Date or student (if over 18 years of age)