Buckeye Local School District
Request for Student Records Release
Please print clearly
Please send a copy of my records
to:
Name: __________________________________________________________
Address: ________________________________________________________
City, State Zip ____________________________________________________
Name While Used In School: _________________________________________
Date Last Attended:
____________________ Birthday: ____________________
Please check the school that you attended and mail along with the $2.00 fee to
the address listed.
Please make check or money order payable to Buckeye Local.
| ____ | Buckeye Local High School 10692 State Highway 150 Rayland, Ohio 43943 |
____ | Buckeye North High School 1004 Third Street Brilliant, Ohio 43913 |
| ____ | Buckeye South High School 100 Walden Avenue Tiltonsville, Ohio 43963 |
____ | Buckeye SouthWest High
School 100 Walden Avenue Tiltonsville, Ohio 43963 |
| ____ | Buckeye West High School c/o Buckeye Local School District Attention: Records 6899 State Route 150 Dillonvale, Ohio 43917 |
Applicants Signature: _______________________________________________
Parent's Signature (if under 18) ________________________________________
Your Address: ____________________________________________________
Your City State Zip_________________________________________________
Email Address: _______________________ Today's Date:___________________
******************************************************************************
For School Use Only
Date Received: ___________________
By ________________________
Date Sent: _______________________
By ________________________