Middlebury Academy Request Form

Middlebury Academy Records Request Form

Use this form to request a copy of student records.
Authorization to Release Information
Parent Name

First NameLast Name
Student Name

First NameLast Name
Birthday

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
From the most recent School/Institution Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates of Attendance

MonthDayYear
Starting Date
Dates of Attendance

MonthDayYear
Ending Date
SSID
The following records may be released.

√ Transcripts of subjects and grades
√ Ohio Achievement/Proficiency Test Results
√ Attendance/Truancy
√ Standardized Test Results
√ Psychological or Other Individual Test Results
√ Gifted Assessments
√ 504 Accommodation Plan
√ Health Records
√ English Language Proficiency Assessments
√ Birth Certificate
√ Special Education Records, Including IEP, MFE, and behavior Plan
√ Any other documents pertaining to student
The records may be released to: South Side Academy Address: 1400 Oak Hill Avenue, Youngstown, OH 44507

Telephone/fax: 330-774-5562

Email: info@southsideedu.org
Request
I am authorizing the release for these reasons. Please check one.

I am the subject of these records and 18 years of age or older.I am the parent, guardian, or custodian of the subject of these records and the subject is under 18 years of age.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Middlebury Academy Records Request Form