Student Records Release - MAP St. Louis

This Section for Office Use Only Date Received __________ Academic Year __________

Student Records Release To be considered for the main admissions cycle, this form (along with the supporting materials) must be received by January 27, 2017.

INSTRUCTIONS Please complete the top portion of this form, and then deliver/submit this form directly to your child’s current school. If your child has attended multiple schools, please submit a copy of this form to all previous K-6 school(s).

________________________________________________________________________________________ Applicant’s Full Name Date of Birth Grade(s)

I authorize MAP St. Louis to obtain/release the following records:     

Academic Records Attendance & Disciplinary Records Standardized Test Scores All Special Education Records, including but not limited to IEPs, Psychological Evaluations, and Social Development Studies All other pertinent information

________________________________________________________________________________________ Parent/Guardian Signature (relationship) Date ________________________________________________________________________________________ Parent/Guardian Signature (relationship) Date

SCHOOL OFFICIAL Please send this form with the student’s records to one of the following: Mail

Email

Fax

MAP St. Louis Attn: Student Records 3840 Washington Blvd. St. Louis, MO 63108

[email protected]

314.400.7290

NOTICE OF NONDISCRIMINATORY POLICY MAP St. Louis admits students of any race, color, gender, creed, sexual orientation, religion, or national and ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to students in the school. MAP St. Louis does not discriminate on the basis of race, color, creed, gender, sexual orientation, religion, or national and ethnic origin in the administration of its admission policies, educational policies, hiring policies, scholarships, and other school-administered programs.