RECORDS REQUEST

Name of Last School Attended _____________________________________________

School Address _____________________________________________________________

Street Address City State Zip Code

School Phone Number _____________________________________________________

School Fax Number _____________________________________________

Student (s) Name _______________________________ DOB __________Grade ____

_______________________________ DOB __________Grade ____

_______________________________ DOB __________Grade ____

The above named student(s) have been registered at Hickory Center Elementary. We would appreciate receiving the following information:

_____ EDUCATIONAL RECORDS- Include levels, progress reports, standard tests, scores, educational evaluations, most recent grade card

_____ MEDICAL RECORDS- Include physical and all health and immunization records.

_____ STUDENT SERVICE INFORMATION- Include special education records, as well as all psychological, psychiatric, and planning and placement team recommendations.

_____ RACE/ETHNICITY Reporting Form

_____ HOME LANGUAGE SURVEY (HLS) Form

_____ ENGLISH LANGUAGE LEARNER (ELL) RECORDS- Evaluations, scores, levels,

progress reports

Please deliver, mail, or fax completed information to the school that your child will be attending.