Spaulding High School
Rochester, New Hampshire 03867

AUTHORIZATION TO REQUEST OR RELEASE RECORDS

Date________________ Name of Student________________________________________
Year of Graduation_______ or current Grade_______ Date of Birth______________________

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I grant authorization to RELEASE the following records:

_____ high school transcript

_____ withdrawel grades

_____ health records

_____ accumulative folder

_____ other____________

 To:___________________________________________________

Address_______________________________________________
_____________________________________________________

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I grant authorization to Spaulding High School to OBTAIN the following records from:_______________________________________________________________________

_____ high school transcript

_____ numerical withdrawal grades

_____ health records

_____ accumulative folder

_____ # unexcused absences this year

_____ other___________________

Please forward records to:












 Guidance Office
Spaulding High School
130 Wakefiled Street
Rochester, NH 03867

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Authorized Signature________________________________________________________

(if student is under 18, a parent or guardian must sign)

Address____________________________ Telephone number_______________________

(home)

______

____________________________                             ________________________

(work)