PARENT AUTHORIZATION FOR RELEASE OF RECORDS
Westlake City Schools
24525 Hilliard Blvd.
Westlake, Ohio 44145
(440) 871-7300
The above-named school, school district, agency or individual is hereby authorized to
release to the school or school district, agency or individual named below the following
portions (please check) of the school records of:
Name of Student: __________________________________________
Westlake School of Attendance: _____________________________
Grade:_____________________
Birthdate:___________________
______
______
______
______
Permanent files/Cumulative Records
Medical and Health Records
Individual Psychological/Speech and Language Records
Other: _______________________________________
Send Records/Reports to:
(Name of School, School District, Agency or Individual)
(Address)
City
State
Zip Code
New residential forwarding address will be:
_____________________________________________
Address
____________________________________________________________________
City
State
Zip
______________________
Date
_________________________________________
Signature of Parent/Guardian