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Request for Student Records

Please complete the form below. Required fields marked with an asterisk *

Today's Date:*

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Prior School Address and Phone/Fax Information*

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Please send all pertinent records, which include results of group tests, and all health/medical records and reports, attendance and academic data as well as grades to date of leaving your school. If the student(s) qualifies for special education or any other programs, please send all information including psychological evaluations, speech and language evaluations, special education programs, including IEP's and other information of a confidential nature.

Student's Name*

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Date Enrolled:*

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Grade:*

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I certify that the above information is accurate*

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Yes

Signature*

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Parent/Guadian's Full Name:*

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Please release records to:

Ipswich Public School

PO Box 306

Ipswich, SD 57451

OR

[email protected]

Confirmation Email

Confirmation Email *

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